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. 2019-01B

(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 AGENCY : _______________________________________________________________

ADDRESS : _______________________________________________________________

I, ____________________________________________of legal age, Filipino, after having been duly

sworn to in accordance with law, do hereby undertake that:

1. I am the Head of __________________________________, being its _________________________;

(Department/Agency) (Position)

2. I am authorized to apply for the issuance of a Certificate of Authority-Law

Enforcement Agencies (CA-LEA) under COMELEC Resolution No. __________;

3. All the officers and personnel in the Form 19A-01B attached and contained in the
compact disc (CD) submitted herewith, which is certified correct by the Chief of the
Agency’s Personnel Division, are in the regular plantilla of our agency, receiving regular
compensation for the services rendered therein and performing actual law enforcement
and/or security functions;

4. The list of personnel does not include consultants, part-time, temporary, contractual
and casual employees, job-order and confidential agents (CAs), whether receiving
compensation from the government agency or not;

5. The listed firearms described in Form 19A-01B are presently in the possession of the
authorized officers and personnel named therein; the data are real, true and correct.

6. Our Officers and Personnel listed in the Roster, when in the possession of firearms,
shall be:

a) in the regular plantilla of the said agency and receiving regular compensation for the
services rendered therein;
b) in the agency-prescribed uniform showing clearly and legibly, at all times, the name,
rank and serial number, or in case rank and serial number are inapplicable, the
agency-issued identification card showing clearly the name and position, which shall
remain visible at all times;

Page 1 of 2
AFP/PNP/LEA - Agency
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.

c) duly authorized to possess firearm and to carry the same outside of residence by
means of a valid permit to carry or by virtue of a valid mission order or a letter order;
and
d) in the actual performance of official law enforcement and/or security duty, or in
going to or returning from his residence/barracks or official station;

7. The 4” x 5” colored picture with full description of the authorized uniform for the officers
and personnel is in Form 19B which is attached hereto.

8. 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).

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.

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)
HEAD OF AGENCY

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-01B and Form 19B

Page 2 of 2
AFP/PNP/LEA - Agency