Revised OMB Form1-August2024
Republic of the Philippines
Office of the Ombudsman
1.APPLICATION WITHOUT BASIC REQUIREMENTS:A)PHOTOCOPY OF FRONT AND BACK O FVALID ID OF THE APPLICANTAND B) PAYMENT, WILL NOT BE PROCESSED.
2.WRITE LEGIBLY, PUT "N/A" IF NOT APPLICABLE AND SIGN THE APPLICATION FORM
APPLICATION FOR OMBUDSMAN CLEARANCE(OMB Form1)
NUMBER OF ORIGINAL COPIES REQUESTED: 1
P150.00 per copy
APPLICANT'S INFORMATION:
Buhisan Elsa Ontiveros F
First Name Middle Name Last Name Suffix Sex
(e.g.,Jr.Sr.II,IIIetc.)
Date of Birth 10/19/1973
If married, mother's maiden surname Lauron
mm/dd/yyyy
(for female applicant)
Contact Nos.: 09549942858 Email Address:
elsaobuhisan@gmail.com
`
Current Position: Master Teacher 1
Agency/Office Name: Department of Education From: July 3, 1995 To: July 1, 2024
Agency/Office Address:
Department of Education Division of Ozamiz City, IBJT Compound, Ozamiz City 7200
Zip Code
Purok 4, Carangan, Ozamiz City 7200
Present Home Address:
ZipCode
MODE OF PAYMENT: Please check (√) the appropriate box.
Cash
Postal Money Order Others, please specify: Exempted
Payable to the "Office of the First time jobseeker
LANDBANKLink.BizPortal Ombudsman-Clearance Fees" Indigent
*One time exemption
and only for one original copy
MODE OFRELEASE: Please check (√) the appropriate box.
pick-up at OMB office registered mail
agency/office
courier service present home address
*prepaid envelope to be provided by clearance delivery address
Purok 4, Carangan, Ozamiz City
the applicant/client w/ full delivery
address
IN CASE APPLICATION IS FILED BY AUTHORIZED REPRESENTATIVE OR REQUESTER IN BEHALF OF THE DECEASED PERSON
Please check (√) the appropriate box.
Authorized Representative Requester in behalf of the Deceased Person
First Name Middle Name Last Name
Relation to Applicant/Deceased:
Signature Over Printed Name of Client Date
I declare that the answers given above are true and correct to the best of my knowledge and belief. I respectfully request
your good office to issue a clearance in my favor. By signing below, it is understood that the personal information
submitted will be used solely to provide the services requested, handled properly and not shared with any unauthorized
person in accordance with the Ombudsman Privacy Notice.
ELSA O. BUHISAN May 16, 2025
Signature Over Printed Name of Applicant Date
TO BE ACCOMPLISHED BY CLEARANCE PERSONNEL
ControlNumber: Date&TimeReceived:
DateFiled: DueDate:
ModeofFiling: DateAssigned
ModeofPayment: AssignedVerifier:
Remarks: Name&Signature:
THISFORM ISNOTFORSALE.THISCANALSO BEDOWNLOADEDTHRUTHEOMBUDSMANWEBSITE ATwww.ombudsman.gov.ph
March 31, 2015
Deputy Ombudsman
Office of the Ombudsman
Davao City
Subject: Request for Reissuance of Clearance Certificate
Dear Sir/Madam,
I am writing to respectfully request the reissuance of my Clearance Certificate from the Office of the Ombudsman. The
initial certificate I obtained was issued prior to my official retirement date, and as a result, the Government Service
Insurance System (GSIS) was unable to accept it.
To comply with GSIS requirements, the Clearance Certificate must be issued after the date I formally tendered my
retirement/resignation. I would like to kindly request a new certificate reflecting this updated issuance date to complete my
application process with GSIS.
Thank you very much for your attention to this matter. I look forward to your favorable response.
Respectfully yours,
ELSA O. BUHISAN
