ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAHAIAJAKALAMANAOAPAQARASATAUAVAWAXAYAZBABBBCBDBEBFBGBHBIBJ
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REPUBLIC OF THE PHILIPPINES
(Revision No. xxx Date xxxxx)
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KAGAWARAN NG PANANALAPI
KAWANIHAN NG INGATANG-YAMAN
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RISK NUMBER
(to be accomplished by BTr Officer)
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(BUREAU OF THE TREASURY)
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REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF
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FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER
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 INSTRUCTIONS:
1. ACCOMPLISH THIS FORM CORRECTLY
3.MARK APPROPRIATE BOXES WITH CHECK
"ü"
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2. PRINT ENTRIES LEGIBLY IN CAPITAL LETTERS
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TYPE OF APPLICATION:
NEW
RENEWAL
CANCELLATION, please proceed
OLD RISK NUMBER:
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to Item Nos. 24-32
For Renewal
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1. NAME
2X2 ID PHOTO
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SurnameGiven NameName Ext. (e.g., Jr.)Middle Name
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2. ADDRESS
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3. DATE OF BIRTH (mm/dd/yyyy)
4. PLACE OF BIRTH
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5. SEX
7.CIVIL STATUS
8. CONTACT NUMBER
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MALE
FEMALE
SINGLE
WIDOWED
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6. TIN
9. EMAIL ADDRESS
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MARRIED
SEPARATED
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10. MONTHLY INCOME (Salaries,allowances,business income and the like)
11. ESTIMATED MONTHLY EXPENSES
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12. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or private sector?
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YES
NO
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If yes, give details:
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13. a. Have you ever been found guilty of any administrative offense? b. Have you ever been found guilty of criminal case before any court?
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YES
NO
YES
NO
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If yes, give details:
If yes, give details:
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Case No/s.
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Date Filed:
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Status of Case/s:
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14. CHARACTER REFERENCE (Individual must not be related up to the fourth degree by consanguinity or affinity to applicant)
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NAMEADDRESSCONTACT NUMBER
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15.I declare that the answer to the foregoing questions are true to the best of my knowledge and belief. I fully understand that any misrepresentation made in this application and supporting documents shall cause the filing of administrative/criminal case(s) against me.
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Government Issued ID
:
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ID/License/Passport Number
:
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Date/Place of Issue
:Signature over Printed Name /Date Accomplished
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16.SUBSCRIBED AND SWORN to before me this_________________________, affiant exhibiting his/her validly issued Government
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 ID as indicated above.
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Doc. No.
;
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Page No.
;Signature of Officer/Person Administering Oath
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Book No.
;
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Series of
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