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CBFSP FORM NO. 2017-02 SA
fin 3 copies; with CD attached)
Republic of the Philippines
COMMISSION ON ELECTIONS
Intramuros, Manila
COMMITTEE ON THE BAN ON FIREARMS AND SECURITY PERSONNEL
(CBFSP)
Barangay and Sangguniang Kabataan Elections
May 14, 2018
APPLICATION FOR AUTHORITY TO BEAR FIREARMS
with AFFIDAVIT OF UNDERTAKING
NAME OF SECURITY AGENCY:
, of legal age, Filipino, after having been duly
sworn to in accordance with law, do hereby undertake that:
1. Lam the of the above-named security agency
(Position)
and [am authorized to apply for the issuance of a Certificate of Authority - Security
Agencies under COMELEC Resolution No. . My Certificate of Employment.
and Authorization is attached hereto as Annex “A™.
2. Our Security Agency is duly licensed to operate by the Philippine National Police.
Attached hereto as Annex “B” is a photocopy of our License to Opera‘e.
3. All the personnel in Form17A-02 attached hereto and contained ir the compact disc
(CD) submitted herewith, are in the regular plantilla of our agency, receiving regular
compensation for the services rendered therein and performing actual security or
protection services in their assigned stations.
4. The data, including the name/s and licenses of the security personnel with details of their
authorized firearms, in Form 17A-02, are real, true, and correct.
5. Our security personnel, when in the possession of firearms, shall be:
a. in the agency-prescribed uniform with the agency-issued ‘dentification card
prominently displayed and visible at all times, showing clearly the name and position;
b. in possession of a valid License to Exercise Security Profession (LESP) with Duty Detail
Order (DDO), and:
c. inthe actual performance of duty at his specified place or area of duty.
6. The 4” x 5° colored picture with full description of the authorized uniform for the
security personnel is in Form 17B which is attached hereto;
Page 102
Security Agency7. The actual place/area of duty of the security personnel are stated in the latest Monthly
Disposition Report (MDR) which is attached hereto as Annex “C”,
8, All the required licenses and permits are still valid, updated and will not expire during
the election period from April 14, 2018 (Saturday) to May 21, 2018 (Monday).
9, I have paid the amount of _ eat (Pk ) as
evidenced by O.R. No. dated
10.1 acknowledge that the filing fee is non-refundable, whether or not the application is
approved.
11.[ 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.
12. 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.
IN WITNESS WHEREOF, I have hereunto affixed my signature and scal of my office on
this __day of. . 201__. in the City of . Philippines.
(Name and Signature}
HEAD OF AGENCY OR
AUTHORIZED REPRESENTATIVE
Republic of the Philippines}
)S.8.
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__
NB. Please attach Form 17A-02, Form 17Band Annexes
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Form 17A-02 The data in this application, including those contained in the compact disc, are submitted to the PNP/AFP for the purpose
of evaluating and processing of this application.
CERTIFIED LIST OF OFFICERS AND PERSONNEL
with THEIR AUTHORIZED FIREARMS:
NAME OF AGENCY:
ADDRESS :
LICENSE TO OPERATE NO:
- T
Firearm Firearm
First, Second | Middle | Suffix | Employee | Rank/ Make/
eae Name Name |Name| No. | Position | P°SrPH" | model rea | eee ena
Thereby certify that the names herein are: (1) in regular employees of the Agency, (2) performing actual security functions: receiving regular compensation for the
services rendered in the Agency, and (2) duly authorized and sanctioned by the Agency to bear, carry and transport firearms in the exercise of their security
functions and duties. I further certify that the firearms described are: (1) duly registered firearms, and (2) covered by duly issued and valid DDOs and LESP.
Head of Agency/Head of Agency's HR Department
(Name, Position and Signature)
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Securtty Agency