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58(A) Application for Bond

Bureau of the Treasury application form for bond of accountable officials and employees of the Republic of the Philippines

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: GENERAL FORM NO. 58 (A)
(Revised March 24, 1976)

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
(Bondable Position)

at
(Name of Office, Bureau or Government-Owned or Controlled Corporation)

Province of
APPLICANTS TO HOLD BONDABLE POSITIONS MUST ANSWER ALL QUESTIONS IN FULL
(ALL REPLIES CONFIDENTIAL)
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
Liabilities.
7 Name three (3) references:

, attach latest statement of Assets and

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 from 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
20
IN THE PRESENCE OF:

(Witness)

(Signature of Applicant)

SUBSCRIBE AND SWORN TO before me this
day of
The applicant presented to me his/her Residence Certificate No. Aissued on
Doc No.:
Page No.:
Book No.:
Series No.:

20
issued at

(Signature of Officer Administering Oath)

GENERAL FORM NO. 58 (A)
(Revised March 24, 1976)

CERTIFICATION OF VERIFICATION
AND OBSERVATION

The following description of the applicant is required to be filled and certify
by a 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
therefore hereon.

1
2
3
4
5
6
7
8
9

Height
Weight
Complexion
Face with or without smallpox
Color of eyes
Color of hair
Color of mustache
Color of beard
Birth and other marks on the:
(A) Face
(B) Body
(C) Hands
(D) Arms
(E) Legs and feet

PICTURE
(Passport size or 2 X 2 )

THIS IS TO CERTIFY that I verified the truthfulness of the answers to
the questions contained on the face of this form and found them to be
correct in so far as can be ascertained. I further certify having inquired
into the character, honesty, integrity, and efficiency of the within
applicant and found him to be
worthy of trust, confidence and reliance. Hence, the recommendation
of the undersigned as expressed in his 1st indorsement contained on
General Form 57-A to which this form (General Form 58-A) is attached.

(Head of Office of Agency)

Date:
I CERTIFY to the correctness of the foregoing description
of
(Name of Physician, Department of Health)

20

(Official Designation)

20
 
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