All information stated in this application are subject to Resolution No.

2048-A and the Data Privacy Act of 2012 (R.A. No. 10173), and are deemed confidential and no access by the public is
authorized.

All authorized recipients of any personal data, personal information, privileged information and sensitive personal information contained in this document, including other pertinent
documents attached thereto that are shared by the Commission on Elections in compliance with existing laws and rules, and in conformity with the Data Privacy Act and its Implementing
Rules and Regulations, as well as the pertinent circulars of the National Privacy Commission, are similarly bound to comply with said laws, rules and regulations, relating to data privacy,
security, confidentiality, protection and accountability.

CBFSP FORM NO. 2019-01C

(in 3 copies; with CD attached)

Republic of the Philippines

COMMISSION ON ELECTIONS
Intramuros, Manila

COMMITTEE ON THE BAN ON FIREARMS AND SECURITY PERSONNEL

(CBFSP)

National and Local Elections

May 13, 2019

APPLICATION FOR AUTHORITY TO BEAR FIREARMS

with AFFIDAVIT OF UNDERTAKING

NAME OF CASHIER/DISBURSING OFFICER/ HRI: _____________________________________

COMPANY: _____________________________________________________________________________

ADDRESS: _______________________________________________________ Pls attach latest 2x2

photo
___________________________________________________________________
(taken within the last
I, ____________________________________________of legal age, Filipino, six months
after having been duly sworn to in accordance with law, do hereby
undertake that:
1. I am presently the Cashier/Disbursing Officer/ or an HRI
of___________________;
(Position)(Name of Company)

2. I am authorized to apply for a Certificate of Authority-Cashier/Disbursing

Officer/HRI (CA-C/DO/HRI) under COMELEC Resolution No. __________;

3. The nature of my official duties, profession, business or occupation is considered a high

risk individuals and/ or requires me to carry large sums of money or valuables/and or ;

DESCRIBE DUTIES AND RESPONSIBILITIES

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
(Documents to support the above description of duties and responsibilities or being HRI
may be attached as Annex “A”.)

4. The firearms I will bear and carry are described in Form 19A-01C attached hereto and
contained in the compact disc (CD). The data therein are real, true and correct.

5. All the applicable and required permits and license are still valid, updated and will not
expire during the election period from January 13, 2019 (Sunday) to June 12, 2019
(Wednesday). Attached hereto as Annex “B” are photocopies of the said licenses and
permits.

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Cashiers/DO/HRI
All information stated in this application are subject to Resolution No. 2048-A and the Data Privacy Act of 2012 (R.A. No. 10173), and are deemed confidential and no access by the public is
authorized.

All authorized recipients of any personal data, personal information, privileged information and sensitive personal information contained in this document, including other pertinent
documents attached thereto that are shared by the Commission on Elections in compliance with existing laws and rules, and in conformity with the Data Privacy Act and its Implementing
Rules and Regulations, as well as the pertinent circulars of the National Privacy Commission, are similarly bound to comply with said laws, rules and regulations, relating to data privacy,
security, confidentiality, protection and accountability.

6. In addition, the following requirements set forth by Comelec Resolution No. _______ are
hereby attached, to wit:

1. Certification of the employer under oath that I am an employee of the company and
that I am designated as cashier/disbursing officer (Annex “C”);
2. Certified true copy of my latest Income Tax Return (Annex “D”);
3. Certified true copy of my employer’s latest Income Tax Return (Annex “E”).

7. I have paid the amount of____________________________________(Php_________________) as

evidenced by: COMELEC O.R. No.________________________dated______________________.

8. I acknowledge that the filing fee is non-refundable, whether or not the application is
approved.

9. I understand that any misrepresentation or false statement in this Undertaking or its

attachments shall be a ground for the denial of the application or the revocation of an
approved Certificate of Authority. This is without prejudice to the filing of the
appropriate criminal, civil, administrative, and/or election offense charge/s.

10. The statements stated herein are all willingly, freely and voluntarily executed to attest to
the truth of the foregoing facts in connection with this application above-mentioned.

IN WITNESS WHEREOF, I have hereunto affixed my signature and seal of my office on

this ____day of _____________, 201___, in the City of ___________, Philippines.

__________________________________
(Name and Signature)

Republic of the Philippines)

__________________________ )S.S.

SUBCRIBED AND SWORN TO BEFORE me this ____ day of ________________ 201____,

in the City/Municipality of __________________, Republic of the Philippines, affiant personally
appeared before me ___________________________ with Identification No. ________ issued by
_____________ on _______________________ in _________________.

Notary Public/Administering Officer

Document No. : ___________

Page No. : ___________
Book No. : ___________
Series of 201___

N.B. Please attach Form 19A-01C and Annexes

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Cashiers/DO/HRI