Sei sulla pagina 1di 2

REPUBLIC OF THE PHILIPPINES

APPLICATION FOR BOND OF ACCOUNTABLE OFFICIALS AND EMPLOYEES OF THE REPUBLIC OF THE
PHILIPPINES

I, __________________________ of __________________________ hereby apply for bond as a


______________________ in the service of _______________________________ at
____________________________ Province of ______________________________________.
APPLICANTS TO HOLD BONDABLE POSITIONS MUST ANSWER ALL QUESTIONS IN FULL
(ALL REPLIES CONFIDENTAL)
1. Place and date of birth _________________________________________________________
2. Civil status: Single, Married, or Widower / Widow __________________________________
How many persons are dependent on you for support? _______________________________
3. What salary will you receive?___________________________________________________
4. Do you have any income other than your salary? If so, how much and from what source
derived?______________________________________________________________________
5. If engaged in any other business, give particulars and names of partners or associates, if any
_____________________________________________________________________________
6. Indicate Tax Account Number ____________________, attach latest statement of Assets and
Liabilities.
7. Name three (3) references: _____________________________________________________
_____________________________________________________
_____________________________________________________
8. Have you ever been discharged from any position? If so, state particulars _______________
_____________________________________________________________________________
9. Do you carry life insurance? If so, how much, in what company, and to whom payable?
_____________________________________________________________________________________
_______________________________________________________________________
10. Have you ever applied before for bond form any fidelity and guaranty company? If so, when and
where? ______________________________________________________________
11. Do you have any criminal or administrative records? _________ If so, state briefly the nature
thereof _________________________________________________________________
12. Are you a member of any fraternal, social or political society? _______ state the name and nature of
each society ___________________________________________________________
13. What is the estimated total amount of monthly living expenses of yourself and family?____
_____________________________________________________________________________
The answer to the foregoing questions are true to the best of my knowledge and belief, and in
witness whereof , I affix my signature below, this _____ day of ________, ______.

IN THE PRESENCE OF:

____________________________ ________________________
(Witness) (Signature of Applicant)

SUBSCRIBE AND SWORN TO before me this ______ day of _____________ 20 ___


The applicant presented to me his / her Residence Certificate No. A- _____________ issued at
________________________ issued on ____________________________________.

Doc No.: ____________


Page No.:____________
Book No.:____________
Series No.:___________
- ----------------------------------------------------------- CERTIFICATION OF VERIFICATION
The following description of the applicant is required to be filled and certify by a AND OBSERVATION
competent physician of the Department of health in Manila or in the provinces. One
copy of his bust picture must be pasted on the space provided thereof hereon. THIS IS TO CERTIFY that I verified the truthfulness of the answer to the
- -------------------------------------------- questions contained on the face of this form and found them to be correct so far as
1. Height ____________________________________________________________ can be ascertained. I further certify having inquired into the character, honesty,
2. Weight____________________________________________________________ integrity, and efficiency of the within applicant and found him to be
3.Complexion_________________________________________________________ __________________________ worthy of trust, confidence and reliance, Hence, the
4.Face with or without smallpox __________________________________________ recommendation of the undersigned as expressed in his 1st indorsement contained
5. Color of eyes _______________________________________________________ on General Form 57-A to which this form (General Form 58-A) is attached.
6. Color of hair _______________________________________________________
7. Color of mustache ___________________________________________________
8. Color of beard ______________________________________________________
9. Birth and other marks on the: __________________________________________
(A) Face _______________________________________________________
(B) Body_______________________________________________________
(C)Hands______________________________________________________ Date: __________________ 20_____
(D) Arms______________________________________________________
(E) Legs and feet ________________________________________________

I CERTIFY to the correctness of the foregoing description


Of ___________________________________________________________

________ 20 _____ ___________________________


(Medical Officer)