FORM NO. ___ APPLICATION FOR AMNESTY UNDER APPLICANT NO.

_____
PROCLAMATION NO. 75 DATED NOVEMBER 24, 2010

I. PERSONAL DATA
1. Name 2. SN 3. BOS

Rank Family Name First Name Middle Name

4. Address
(2x2 ID picture)
5. Alias/es 6. Sex 7. Civil Status Single Married Widow/er
Separated/Nullity/Annulled
8. Birth Date 9.Birth Place 10. Height 11. Weight 12. Built
/ / Light Medium Heavy
Dd/mm/yyyy

13. Complexion 14. Eyes (Color) 15. Hair (Color) 16. Religion 17. Identifying Marks
Light Fair Dark
18. AFP Unit Assignment during the 19. Designation 20. Educational Attainment
incident: Elementary Secondary
Tertiary Others (Specify)

21. Name of Next of Kin: 22. Address of Next of Kin: 23. Relationship:

24. Character References (Prominent residents of your locality) 25. Address of Character Reference:
a. a.
b. b.

II. CASE DATA

26. Incident involved/participated in:
July 27, 2003 Oakwood Mutiny
February 2006 Marines Stand-Off
November 29, 2007 Peninsula Manila Hotel Incident
NOTE: Applicant shall submit a narration of facts of his involvement/participation as annex A.
I hereby acknowledge that my involvement/participation in the subject incident/s constituted a violation of the 1987 Constitution,
criminal laws and the Articles of War. I hereby recant my previous statements that are contrary, if any, to this express admission
of involvement/participation and guilt.
___________________________________________________
Rank First Name Middle Name Last Name
(Print Name with Signature)
27. Date filed: 28. Status of Case (Civilian Courts)(if any): Pending Acquitted Convicted Dismissed
Attach pertinent court records
29. Status of Case (GCM)(if any): 30. Status of Applicant:
Pending Presently Detained Vol. Surrender Other (Specify)_____________________
Acquitted 31. Status in Service:
Convicted In Active Service Floating Status Suspended
Dismissed Dismissed (date of dismissal)__________________
Attach pertinent court records Others (Specify)______________

III. VERIFICATION
32. I hereby certify that I have read and prepared the foregoing data and the facts contained in my attached “narration of facts
of involvement/participation”, and that the same are true to the best of my personal knowledge. I further certify that this
Application is hereby submitted in connection with my desire to avail of the Amnesty as provided for in Proclamation No.75 dated
November 24, 2010.
In witness hereof, I have signed my name and affixed my thumb marks this ______ day of ____________________ at
_______________________.
____________________________________
(Signature)
Witnessed By: 1)________________________
2)________________________
SUBSCRIBED AND SWORN to before me this ______ day of _______________________ at ____________________

____________________________________
(Administering Officer)

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