PHILIPPINE RETIREMENT AUTHORITY No Male No

SPECIAL RESIDENT RETIREE’S VISA APPLICATION(Form PRA-RRSC-2013-01)Application No.PHILIPPINE RETIREMENT AUTHORITY29F Citibank Tower, Paseo de Roxas, Makati City, 1227 PhilippinesTel No. +632-848-1412, +632-848-1418; Fax No. +632-848-1411E-mail: inquiry@pra.gov.ph; Website: pra.gov.phAttach 2” x 2” coloredphoto taken not morethan 6 months agoAPPLICATION FORM FOR DEPENDENT RETIREE (Entries must be typewritten)□ Dependent - Spouse □ Dependent - ChildLast Name First Name Alias (AKA) ReligionGender□ Male□ FemaleDate of Birth Place of Birth NationalityID No.Civil Status□Single □Married □ Divorced □ WidowedHeightNationality 国 籍Passport No. Place of Issue Date of Issue Valid UntilWeightHome Country Address (Please specify)Telephone No.Fax No.Mobile No.E-mailPrimary Address in the Philippines(Please specify)Secondary Address in the Philippines(Please specify)Telephone No.Fax No.Mobile No.E-mailPrincipal Retiree InformationName of Principal:Included in this application? □Yes □No (Please provide principal’s SRRV information)SRRV No.Date Issued□ SMILE □ Classic □ Courtesy □ Human TouchFamily InformationFor applying dependent-spouse please list name(s) of children below 21 years old; forapplying dependent-child, please list name(s) of siblings.Name: Date of Birth Age ID No. (Required) Included in your application?□Yes□NoName: Date of Birth Age ID No. (Required) Included in your application?□Yes□No

Name: Date of Birth Age ID No. (Required) Included in your application?□Yes□NoName: Date of Birth Age ID No. (Required) Included in your application?□Yes□NoParent’s InformationName of FatherAgeName of MotherAgeName of Contact Person inCase of EmergencyContact No. Nationality: RelationshipAddressDate of Arrival in the PhilippinesExpiration Date of TouristVisa / OthersEntry Visa to the PhilippinesHave you visited Philippines prior to this travel? □ Yes □ NoIf the answer is “Yes”, What kind of entry visa?□ Tourist Visa □ Working Visa □ Investment Visa□ Missionary Visa □ Student Visa □ Others (Please specify) _________________Last three years residencePeriod of stay (mm/yyyy - mm/yyyy)Address1 _____________________________ ___________________________________________________2 _____________________________ ___________________________________________________3 _____________________________ ___________________________________________________5 _____________________________ _________________________________________________Educational Attainment School and Location From/To (mm/yyyy - mm/yyyy)1 _______________________________ __________________________ _______________________2 _______________________________ __________________________ _______________________3 _______________________________ __________________________ _______________________

Plans /Future Activities in the Philippines□ Tourism/Travel□ Others (Please specify)□ Employment□ Investment□ EducationBy affixing my signature, I hereby certify that theinformation above are true and correct and that anymisrepresentation on my part will be grounds fordenial of SRRV and/or revocation of my current Visa.I also commit to inform PRA in writing, of anychange of information presented here:Accredited Marketer (if any):Registered Name of Marketer:PRA Accreditation No:Telephone No:Signature of Applicant:Date Signed:(To be accomplished by PRA Personnel)---------------------------------------------------------------------------------------------------------------------------------Date of Receipt of Application Form: _____________________________Papers Reviewed & Certified Complete by: (Please indicate complete name, designation, and long-form signatureComments / Remarks:------------------------------------------------------------------------------------------------------------------------------------------------------------(To be accomplished upon issuance of SRRV)------------------------------------------------------------------------------------------------------------------------------------------------------------SRRV Number:Date of Issuance:Date of Oath-taking:__________________________________________________________________________________________