APPLICATION FOR BOND

TO: STRONGHOLD INSURANCE CO., INC.

Unit 2712 27th Floor, AIC Burgundy Empire Tower,
ADB Ave. corner Garnet Road, Ortigas Center, Pasig City

Gentlemen:
I/WE hereby apply for a __________________________________in the sum of Ps. ________________
in favor of ___________________________________________of the purpose of _______________
_____________________________________________________________________________________
NAME : _______________________________________AGE :_______CIVIL STATUS : ________
ADDRESS : (Res) ____________________________________________Tel. No. :______________
(Office)___________________________________________Tel. No.:______________
IF YOU HAVE OWNED THE BUSINESS, HOW LONG HAS IT BEEN ESTABLISHED:_____________________
PREVIOUS POSITION OR BUSINESS CONNECTIONS:__________________________________________
IF EMPLOYED, PLEASE STATE:
Name of Employer : __________________________________Tel . No.:_______________
Address : __________________________________No. of Years: ____________
Position Occupied : ____________________________Monthly Salary: P ______________
Name & Designation of
Superior:___________________________________________________
Previous Employer : _________________________________________________________
LIST OF REAL ESTATE AND PERSONAL PROPERTIES OWNED:
Date Location of Area Assessed Value Encumbrance
Acquired Description of Land Land Improvement Amount Paid
________ ________________ _________ ____________________ ____________
________ ________________ _________ ____________________ ____________
________ ________________ _________ ____________________ ____________
TRADEMARK PREFERENCE
Name Address
_____________________________________ _______________________________________
_____________________________________ _______________________________________
_____________________________________ _______________________________________
BANK PREFERENCE
Name of Bank Address
_____________________________________ _______________________________________
_____________________________________ _______________________________________
_____________________________________ _______________________________________
PERSONAL PREFERENCE
Name Occupation Address
_____________________________________ _______________________________________
_____________________________________ _______________________________________
_____________________________________ _______________________________________
OTHER INFORMATION
INSURANCE CARRIED
Name of Company Address Amount Insured
_____________________________________ _______________________________________
_____________________________________ _______________________________________

I hereby certified that the forgoing information is correct and that they are made to induce the
STRONGHOLD INSURANCE COMPANY, INC., to accept this application for bond.

__________________________
(Signature of Applicant)
SIGNED IN THE PRESENCE OF:
__________________________ __________________________

SUBSCRIBED AND SWORN to before me this _______day of _____________________202_____ at the

______________________________Affiant exhibiting to me his/her Community Tax Certificate No.
__________________________issued at __________________on ______________________.

Doc. No. _______

Page No._______
Book No._______
Series of 20