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Attachment 3: Annex D Fidelity Bond Application Form REPURLIC OF THE PHILIPPINES (Revision Nox Date ezas) KAGAWARAN NG PANANALAPE RAWANILAN NO INGATANG-Yamax [RISK NUMBER, IOUREAU OF THE TREASURY) Ei REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER SS Le eee 1 Feces Ll rmewss [_ cweniatonemane [aomarnaier pr ROMEO psanro wa Ere —— eres “Steer Froareor emt mann —Jurcace or warn crass EALU@CUB 1.0 SAN JUAN. BATANGAS . [cre sravus > CO sate (J) woowen [ave Reve you eve been found gly olny sdrinnvaive afnan? |b, ave you ew bron found gy of criminal case below any cout | 4. CHARACTER REFERENCE jus muerte res yp oe ou eee y Ae ‘ODES [COEBRANOO'SALUD- [CRCITCRLTY SAN JUAN, BATANGAS. [ALVIN 0, SAVONTE. FTICALAN, SAN JUAN, BATANGAS [5759371 [vane LANA [LAVA APLAYA. SAN JUAN BATANGAS [5755435 1. | dele ta he arawer wo te foragong quests are te othe bes of my Anowledge and Geel. [Tuy understand that ary Imisrepreserlabon rade the appeaion and suppering documents shal cai2e the ling 0} semioravalctninal cass) agar me Goverment sued 10 TINCARD [Dien Pasapon Nano DatePace ot nse ‘Tuma PRCT 16 SUBSCRIBED AND SHORW olor me tart ote Neer ay ass Gonrment oe No + HON. fo SALW Page Mo = ron [Eo oo ee [RSUNG, SAN JUAN BATANGAS, BATANGAS ices, fesion fy i [evan atooaracenr ais ceoces —— — mena ” ee meyer an Sy (ona tao TORRE EE) omer CO wane () treeonyeae S— SS ee oe ee pe fs. TMS 16 TO CERTEY THAT a Head of Agr ‘ ee ai ‘Doran atte se icon i rn, Pe noni meaner spo nd acy he = oom (omeenatnt racesenemtepinee nonke eau, ceowcen [AGENCY ADMIN Tarren Met nested repo ‘mane "cy at hearty utes he et oe 7 srrucaven (] nenewa. [emcewanon ‘rey tong he ove ree art ut

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