COYUITO HOUSE 119 CARLOS PALANCA, JR. ST.

LEGASPI VILLAGE MAKATI CITY

P.O. BOX 3831 CPO 1099 MANILA* TEL NOS. 8104916 TO 35* FACSIMILE 8102991

BOND APPLICATION
(Corporation/Partnership)

The undersigned hereby applies for a PERFORMANCE AND SURETY-DP Bond in the amount
of PHP 1,800,000.00 (30% OF TCP) in favor of *SEE ATTACHED CONTRACT*
(Indicate details of undertaking, or attach copy of contract and/or corresponding documents for which bond
is required)

For consideration. I/We am/are giving hereunder the following information:

1. Name: BROOKSIDE LANE CONSTRUCTION AND DEVELOPMENT ( X ) Corporation
2. Office Address BROOKSIDE LANE ST, SAN FRANCISCO, GEN. TRIAS, CAVITE CITY
3. Nature of Business.........CONSTRUCTION *SEE ATTACHED COMPANY PROFILE*
4. When was it organized/incorporated?...................................................................................
5. How much is the capitalization?.......... PHP 4 MILLION ..........
6. How much is the subscribed & paid-up?........ PHP 1 MILLION .............
7. State the names of Officers/Directors authorized by the Board to sign and the incorporators:
(Please submit pertinent board resolution or secretary's certificate)

SEE ATTACHED BOARD RESOLUTION / SEC CERTIFICATE

8. If you own real estate properties, please give the following particulars(If land, state if titled or
unregistered, whether residential, commercial, or agricultural and also area thereof. If building, state
number of storeys, nature of occupancy (Residential,store,bodega, etc) and type of construction.

Description Location Area Assessed Value Market Value

OFFICE BUILDING GENERAL TRIAS CAVITE 5 MILLION

9 If any of the above-mentioned property/ies are presently mortgaged, please state the following:
Description Name of Amount of Present Due
of Property Mortgagee Orig.Loan Balance Date
a.........................................................................................................................................................
b.........................................................................................................................................................

10. Do you carry fire insurance on any of these properties? If so, please state the following:
Description Name of Amount of Expiry
of Property Insurance Co. Insurance Date
a......................................................................................................................................................
b..........................................................................................................................................................

11. State the names of banks you maintain your current/savings account:
NAME BRANCH
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................

12. Have you ever been issued a bond? ( ) YES ( X ) NO

Surety Company Type of Bond Amount Obligee Expiry Date
a...........................................................................................................................................................
b...........................................................................................................................................................
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The above foregoing statements and representation are true and correct to the best of my
knowledge and belief and are made for the purpose of inducing PRUDENTIAL GUARANTEE AND
ASSURANCE INC.

Dated at..................................this.............. day of......JULY 28, 2017.

Residence Cert No. ...............................................................

Authorized Signature

HIPOLITO P. PAGENTE
(SGD)