BTR-FORM 58A

APPLICATION FOR BOND OF ACCOUNTABLE OFFICIALS AND EMPLOYEES OF THE REPUBLIC OF THE PHILIPPINES
I,*
Full Name
of*
Home Address
hereby apply for bond as a*
Position
Name of Agency/Office*
Address of Agency/Office*
Barangay/City or Municipality
Province
APPLICATIONS TO HOLD BONDABLE POSITIONS MUST ANSWER ALL QUESTIONS IN FULL (ALL REPLIES CONFIDENTIAL)
1.Place and date of birth*

MonthDayYear
Date
2.Civil status: Single, Married, or Widower/Widow*
How many persons are dependent on you for support?*
3.What salary will you receive?*
4.Have you 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*
7. Name three character 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 from any fidelity and guaranty company? If so, when and
where?*
11. Do you have any criminal or administrative records?*
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 all the monthly living expenses of yourself and family?
13. What is the estimated total amount of all the monthly living expenses of yourself and family?
CERTIFICATION OF VERIFICATION AND OBSERVATION

The following description of the applicant is required to be filled and certified 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 therefor hereon.

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
1. Height
2. Weight
3. Complexion
4. Face with or without smallpox
5. Color of eyes
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
(D) Arms
(E) Legs and feet
I CERTIFY to the correctness of the foregoing description of
(Name of Physician)
(Official Designation)
Name of the Head of Agency
Should be Empty:

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

APPLICATIONS TO HOLD BONDABLE POSITIONS MUST ANSWER ALL QUESTIONS IN FULL (ALL REPLIES CONFIDENTIAL)