'->' IMAGE EVALUATION TEST TARGET (MT-3) 1.0 ^1^ 1^ u lit ^" 1.1 0^ p^ ^^ // $ 1 r«0 «>^ •1 ^ • ^l *» V % «> ^» ^ ^ > "O •♦a « 1.^ § ^§» •f OS Sv ^ 5^. i 1: s 15 OS "te «> s 1 J . 8 < «1 i '^ i ?^ 1 •I •1* i « s *«• k ?> « §^ ^ at. : (^ § f« JS "♦* ^- V V § i « 1 .'=0 00 ex •2 ^ ) i »» ^ « « > ^ i i 1 ■i State the nature and amount of any other Debts you owe or liabilities you are under Are you Surety or Endorser for any one ; if so, state amount and particulars ? Were you ever Bankrupt or Insolvent, or did you ever Compound with your Creditors ? If so, state in what year, and what arrangement was made, and whether you hold a discharge What was your occupation or employment previous to this appointment ? Give particulars, and reasons for quitting it Have you ever been discharged from any situation, or been deprived of a commission or other engage- ment ? If so, state particulars Amount of salary or remuneration at which you are engaged in this appointment, and deductions there- from, if any Is there any other, and what allowance to be made to you ? . . Do you furnish further security, in addition to that now applied for ? If so, give particulars Have you hitherto given Security ? If so, please give Names and Addresses of your Bondsmen, and stat& why discontinued- Has a similar proposal ever been made to any and what Guarantee Company ? If so, was it accepted ? . . Give, in the space provided, your occupations, etc., during the past Ten years. OCCUPATION. ADDRESS. NAME OF EMFLOTKR AND ADDRESS. PERIOD OF EACH EMPLOYMENT. From ...i8... . to l8.. , From ...i8... . to i8.. From ...i8... . to i8.. From ...i8... . to i8.. 1 1 1 From ...i8... . to i8.. Give the Names and Addresses of three or four persons who are householders, and not related to you, to whom the Company can refer if necessary- If this is first situation, applicant must give name and address of his Clergyman and last Tutor or Schoolmaster. NAMES. PROFESSION OR TRADE. ADDRESS IN FULL. Mr. Mr. Mr ■ 7 liMrehi declare that I have, in the replies made above, stated the truth witfiout any reservation whatever. Dated eU.. 18 (Signature of Applicant) The AppUoant wilt also livn the Agreement endorsed on the back o( tbU pane. ^^CttVCCXt the undersigned, of the one part, and the LONDON GUARANTEE AND ACCIDENT COMPANY, LIMITED (hereinafter called the " Company "), of the other part : I. — The Company having issued an Agreement guaranteeing certain persons against loss from certain acts or defaults by the said undersigned, the said undersigned hereby agrees to keep harmless and indemnify the Company against all loss, damage, and expense whatever, caused, sustained, or incurred in consequence of any such Guarantee now or hereafter to be given, and against all consequences of acting under this agreement ; and for that purpose hereby authorize the Company, on receipt of notice of an intention by the person holding such Agreement, to make a claim on the Company thereunder, without any notice to the undersigned, to take possession of any money or other property which the Company may find belonging to the undersigned, wherever the same may be, or thought to be. And in case the Company shall make any payment as it shall deem best for recovering the amount of the payment, with interest thereon, and of all costs, charges and expenses paid or incurred in or about investigating or resisting the claim, and of taking, keeping, and selling such property. 2. — A Receipt on the Policy purporting to be signed by the person entitled to give a discharge thereunder, and stating the amount paid by the Company, shall be conclusive evidence as to the amount of the payment, and that the Company was liable thereto and has duly paid the same. 3. — The undersigned agrees to do and execute any deed or thing as may be necessary, in order more effectually to give to the Company the rights and powers herein expressed to be given. Dated this day of 18 Witness Sigtiatnre of Employed Address Address