Deparment of Education

Division of Laguna

FIDELITY BOND APPLICATION AND RENEWAL FORM

Please insert scanned picture
here 2x2

PERSONAL INFORMATION
1 Name Middle Name SurName Name Ext.

SCHOOL/ DISTRICT:
DESIGNATION/POSITION:
DATE OF DESIGNATION OR ASSUMPTION OF ACCOUNTABILITY:
STATION/DIVISION:
2 ADDRESS
Street/Bldg/Unit:
Barangay:
Municipality/Province:

3 Date of Birth: 5. Gender:

4 Place of Birth: 6. TIN No.:
7 Civil Status: 8. Contact Number
9 Email Add: 10. Monthly Income:
11 Estimated Monthly Expenses:

12
Have you ever been separated from the service in any following modes: resignations, retirement, dropped from the rolls,
dismissal, termination, end of term, finished conract or phased or (abolition) in the public or private sector?
If Yes, give the details here:

13a Have you ever been found guilty of any administative offense?
If Yes, give the details here:

13b Have you ever been found guilty of any criminal case before any court?
If Yes, give the details here:

Case No/s:
Date Filed:
Status Case/s:
14 CHARACTER REFERENCES
NAME ADDRESS CONTACT NUMBER
A
B
C

15 GOVERNMENT ID ISSUED :
ID CARD NUMBER:
DATE ISSUED:
PLACE ISSUED:

16 AMOUNT OF ACCOUNTABILITY
Amount of Accountability (P) Bond(P) Premium (P)
100,000.00 75,000.00 1,125.00

17 DATE OF EXPIRATION OF BOND:

18 DATEOF DESIGNATION OR ASSUMPTION OF ACCOUNTABILITY: