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M.H. Del Pilar ST., Bayambang, Pangasinan: General Form No. 58 (A) (Revised March 24, 1976)

This document is an application for a bond for an accountable government position. It collects personal information about the applicant such as name, address, birthdate, civil status, dependents, salary, assets, references, past employment history, insurance, and estimated living expenses. The applicant affirms that their answers are true and the application is signed and notarized. A certifying official also verifies the truthfulness of the answers and attests to the character, honesty, and integrity of the applicant, recommending them for the bonded position.

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436 views2 pages

M.H. Del Pilar ST., Bayambang, Pangasinan: General Form No. 58 (A) (Revised March 24, 1976)

This document is an application for a bond for an accountable government position. It collects personal information about the applicant such as name, address, birthdate, civil status, dependents, salary, assets, references, past employment history, insurance, and estimated living expenses. The applicant affirms that their answers are true and the application is signed and notarized. A certifying official also verifies the truthfulness of the answers and attests to the character, honesty, and integrity of the applicant, recommending them for the bonded position.

Uploaded by

RaulJunioRamos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd

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, RAUL JUNIO RAMOS of M.H. DEL PILAR ST., BAYAMBANG, PANGASINAN


hereby apply for bond as a HEAD TEACHER I in the service of
(Bondable Position)
DEPED CATALINO CASTAṄEDA ELEMENTARY SCHOOL at SANLIBO, BAYAMBANG
(Name of Office, Bureau or Government-Owned or Controlled Corporation)
Province of PANGASINAN

APPLICANTS TO HOLD BONDABLE POSITIONS MUST ANSWER ALL QUESTIONS IN FULL


(ALL REPLIES CONFIDENTIAL)

1 Place and date of birth BAYAMBANG, PANGASINAN, SEPTEMBER 17, 1973


2 Civil status: Single, Married, or Widower/Widow MARRIED
How many persons are dependent on you for support? 1
3 What salary will you receive? 29, 621.00
4 Do you have any income other than your salary? If so, how much and from what source derived?
NONE
5 If engaged in any other business, give particulars and names of partners or associates, if any
NONE
6 Indicate Tax Account Number 197-971-687 , attach latest statement of Assets and
Liabilities.
7 Name three (3) references: SHEILA MARIE A. PRIMICIAS
ELY S. UBALDO
MARY JOY C. AGSALON
8 Have you ever been discharged from any position? If so, state particulars NO

9 Do you carry life insurance? If so, how much, in what company, and to whom payable? YES
GSIS

10 Have you ever applied before for bond from any fidelity and guaranty company? If so, when and
where? NO
11 Do you have any criminal or administrative records? NONE If so, state briefly the
nature thereof
12 Are you a member of any fraternal, social or political society? NO State the name and
nature of each society
13 What is the estimated total amount of monthly living expenses of yourself and family?
22,000.00

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:

ANTHONY E. RICO
(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- 16744558 issued at
ROSALES, PANGASINAN issued on SEPTEMBER 21, 2020

Doc No.:
Page No.:
Book No.:
Series No.: (Signature of Officer Administering Oath)
GENERAL FORM NO. 58 (A)
(Revised March 24, 1976)

CERTIFICATION OF VERIFICATION
The following description of the applicant is required to be filled and certify AND OBSERVATION
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. 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
1 Height 5 FEET, 8 INCHES into the character, honesty, integrity, and efficiency of the within
2 Weight 90 KILOGRAMS applicant and found him to be
3 Complexion FAIR PICTURE worthy of trust, confidence and reliance. Hence, the recommendation
4 Face with or without smallpox WITH (Passport size or 2 X 2 ) of the undersigned as expressed in his 1st indorsement contained on
5 Color of eyes BLACK General Form 57-A to which this form (General Form 58-A) is attached.
6 Color of hair BLACK
7 Color of mustache BLACK
8 Color of beard
9 Birth and other marks on the: SHEILA MARIE A. PRIMICIAS, CESO VI
(A) Face OIC, Office of the Schools Division Superintendent
(B) Body (Head of Office of Agency)
(C) Hands
(D) Arms
(E) Legs and feet
Date: 20

I CERTIFY to the correctness of the foregoing description


of

(Name of Physician, Department of Health)

20 (Official Designation)

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