Attachment 3: Annex D Fidelity Bond Application Form KAGAWARAN NG PARARALAML wo KAWANIHAN NO INGATANG-YAMAN (UREAU OF THE TREASURM) [REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER ACCOM TNS TORIGOMEGT _ 96MM APROMRATE BONES LW 1 TS EGY CATAL LETTERS, De] new [| enewan [_] eoncetarion ae pecs [a Have you ever been separate rom fhe service Nanya he folowing modes reinalon.rremesSoppea von fe is marl rmination, end ct om, tise corrector phased cut bolton int publ o pra seer? Crs jx ym ete a ws uo Ow Ew ym ote seat ne a sao cow aM ‘ADDRESS. ICP. VATONIO. 15, (declare ta he answer to Pe fropoing questons ave Wut he esto my knowlege and Dele. ty understand Pat ary ‘marepresertaion made i the aggleation and supooring documents shall caus the fing of ac ant me. Goverment eed 1 TINCARD, IDitsonwetPasspot Number SEXBEGBTE———— DatePace of sue TavaMaTMANDAU cry 18. svascnncn ww swormictoemena _TULY By 202 (Das ata stove Doe no eno, Sere! Page Tarr[RIE OF OEE OF AERC CENTRO (Pos), MANDAUE CITY CEBU, CEBU wows ee, | {LGU-BRGY) (nai Fae [SORE OR TORT a cg Oe e co |MANOAUE CITY CEBU. CEBU, 2 Asoonrang cm GireSorev one (A emnet Ot (0S ent) Js. HS 10 CERTIFY THAT. a Mow! ot Aapcy 1 ‘rs uae rosters var ea a tee ae nel a ca erie! ‘aan sop sls ancora karan hangs commenany mn nang ent [El reson tts im On oe dete te pte o 7021 ‘AGENCY ADIN Tonnes hiatal a fenatoe ens ‘aie cay ha have cay enti ne eer TD servation [7] renews. [emeeuusnon ny Se overt rpsName of Office: Centro (Pob,) LIST OF BONDED ACCOUNTABLE PUBLIC OFFICERS a REMARKS pasOnaTON -REVIOUS YEAR'S DATA oe or rusiid cereten ||. TREC EFFECTIVEDATE | sak yo, aa ono [ wirirexome | wTH PeNoWe NAME 2 DitursnrCobectngy ask. ‘APPLICATION | an ‘coveRAce | apwnasreanive | CRANAL, se aS ee ea loa ABE Yes or Wo} | CASE (Vee or) TEVROEA ALEONOER 7) Sangguniang aban ‘sazas] —mavonca ——ra0v00| 2 ¥ % wo oes ia a 7 a ve JOSHUA PARDILO eran Teale wanes] masrona| 7a Prepared By Reviewed 8y cartes ana ee HENRY TERI, JR. I Encoer Ti ches ‘Sgralure ove pried name ‘Sigal over printed Fame ‘Signature over prnioa naa Postion Poston Desgyaton of Auth Ofte! Dote:_o7i0772024Attachment 3: Annex D Fidelity Bond Application For saronic of rus mines ghntserlne ma Dna SAGAWARAN NG PARARALAPL ee AWANIAN NG INGATANG-YAMAN TBUNEAG OF THE TREASURY [REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER " Aecouran na Fora Gonnecrsy— suancarmnarnareores LJwmnouar 77 911035196 [se Have you eve bon found gly of any waist conse? Cs Jno yes gre ows [S20EZT 43107 1s declare tat he answer to he foraging questone are wus to the best of my Krawacpe and bell. 4alyunderstar hat any marepresenon made i ths appcaton ard suggerng documers shall cause te eg of admetatve'cimina casts) pas me Goverment ised 10 TINCARD i ‘DiucensePasepon Number: SBSZZIEIE—— PONGOS 107101/202 DatePlace of a0 ‘TaBieago MANDAUE crry Rane Oa Mores 1% SUBSCRIED ANO SWORN toteloe mene [ceNTRO (pos ), MANOAUE CITY CEBU, CEBU Jicu-srcy) nase rae ————_ axe (Ancacrg One ° JMANDAUE crry CEBU, CEBU asowor Ot Sines One [F sratoxenason Pam omnes JbARANGAY CENTRO, MANDAUE CITY ey rate reney |2)Prery Plt 8 Egat ett ae pare or Rar [cue or naar tr One CC cwentent to ease ae te ce SORTES, 0710772021 27 ADMIN Sorrow Pet res ot be Aye TRIOUNT OF BOND RECOMMENDED Js. AuOUNT OF Bono PREM PAYABLE 5,000.0] 4,350.00 ‘Wiech al vcr eva ne gee [[] mrrucanon [] nenewar [J carceusnon ets ne emo neo arm ee SS eeof Office: Centro (Pob,) LIST OF BONDED ACCOUNTABLE PUBLIC OFFICERS PREVIOUS YEAR'S DATA REMARKS DESIGNATION pcan) TYPE OF EFFECTIVE DATE oxo [wim Penoe | wii PENDING NAME OF PUBLIC OFFICER| VIE Cray | (0 Osbusototectng” RISK NO. i ae | ee soa ottced From [To OVERAGE | ADMIMSTRA MAL ‘Sianing Oticer accounrapuity| pono | PREM aren (CASE (e001 No) | CASE (Ys ore) PONGOS,MARIERIA New| SaRIRERE aan waa] aspoo00] sasooo) aye) No ry Totate sxe] spoon] saso00| Prepared By Reviewed By HENRYK. ORI, ‘Sigraive over printed name Pesiton Dote:_g772021 HENRY OAIO. UR. 1 encoder Signature ovr pinied name Poston ‘Signature over print name Designation of Authorized Oficial