PHILIPPINE ECONOMIC ZONE AUTHORITY
PEZA Form. ERD.-4-F.003
Republic of the Philippines
PHILIPPINE ECONOMIC ZONE AUTHORITY
PEZA Building, Roxas Boulevard corner San Luis Street, Pasay City
Telephone: 551-3451 Local 231; Fax: 891-6381 website: .ph
APPLICATION FOR REGISTRATION/ACCREDITATION
AS AN ECOZONE SERVICE ENTERPRISE
(For Customs Broker, Freight Forwarder, Trucker/Hauler and Security Agency)
Customs Brokerage ( ) Application No. ___________
Freight Forwarding ( ) Date Filed ___________
Trucking / Hauling ( ) Official Receipt No. _________
Security Agency ( ) Amount Paid ___________
|Name of Firm: _______________________________________________________________ |
|Address: _______________________________________________________________ |
|_______________________________________________________________ |
|Telephone No. ______________ Fax No. _____________ E-mail_______________________ |
|Applicant’s Representative to PEZA (Contact Person): |
|Name: _______________________________________________________________ |
|Address : _______________________________________________________________ |
|Telephone No. ______________Fax No. ______________E-mail _______________________ |
|Applicant’s Existing Business Registration with: |
|Office Date Registration No. |
|Securities and Exchange Commission (SEC) ________________ ________________ |
|Department of Trade and Industry (DTI) ________________ ________________ Bureau of Customs (BOC) |
|________________ ________________ |
|Social Security System(SSS) ________________ ________________ |
|Bureau of Internal Revenue (BIR) ________________ ________________ Dept. of Labor & Employment (DOLE) – NLRC |
|________________ ________________ |
|Cooperative Development Authority (CDA) ________________ ________________ |
|Others, please specify_________________ ________________ ________________ |
|Nature of Business Entity: |
|Single Proprietorship ( ) __________________________________ |
|Partnership ( ) __________________________________ |
|Corporation ( ) __________________________________ |
|Cooperative ( ) __________________________________ |
|Others (Please Specify) ( ) __________________________________ |
|Issued Licenses/Permits (pls. check) |
|______ Mayor’s Business Permit No. _______________________valid until _____________ |
|______ Customs Brokerage Licenses. Person and Firms, valid until_____________________ |
|______ Copy of Franchise from LTO: Case Decision from LTFRB valid until ______________ |
|______ LTO Registration Certificate/O.R. of vehicles approved under LTFRB Case Decision |
|______ Annual Permit to Operate /Clearance from Philippine Port Authority (PPA) |
|______ Certificate of Accreditation from the Philippine Shippers Bureau (for Sea Freight) |
|______ Authority to Operate from the Civil Aeronautic Board (for Air Freight) |
|______ PNP Clearances: (i) PNP Regular Permit to Operate or Temporary License to |
|Operate valid until ________________________ and (ii) updated firearms Licenses |
|______ Latest Disposition Report validated by PNP-SAGSD dated ____________________ |
| |
|______ Bond with PNP (copy only) valid until _____________________________________ |
|Project Summary: |
|1. Brief Description of the Project (Describe Operations, services to be provided in the Zone, |
|arrangement, etc.) |
|2. Brief Business History of Applicant |
|(Please attach separate sheet, if necessary) |
|3. Organization Chart: (please attach separate sheet) |
|Write – up on the Organization: |
| |
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|4. Financial Institutions from which the Applicant Intends to Obtain Financing: |
|Bank References: |
| |
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|5. Capital Structure- For Corporations Only (Value in Peso) |
| |
|Common Stock Authorized No. Amount (PhP) Par |
| |
|_____________ _____________ _____________ _____________ |
| |Subscribed |Paid-Up |
| | | |
| | | |
|1. Filipino | | |
|a. | | |
|b. | | |
|c. | | |
|d. | | |
|e. | | |
|2. Non-Filipino | | |
| | | |
|Total | | |
| | No. | Value |% to Total |No. | Value |% to Total |
| | | | | | | |
| | | | | | | |
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|6. Capital of Partnership or Single Proprietor |
|Nationality % to Tax |
|(Indicate if Firm’s A/C |
|Name Naturalized) Address Capital Total No. |
| |
| |
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|7. Business Activities Other Than Those Covered by Application |
| |
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|Name of Company Location/Address Product/Service |
|______________________ ________________________ __________________ |
|______________________ ________________________ __________________ |
|______________________ ________________________ __________________ |
|______________________ ________________________ __________________ |
|8. Applicant’s Incorporators (For Corporation Only) |
| |
|No. of Tax No. of Tax |
|Name Shares A/C No. Name Shares A/C No. |
| |
| |
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|9. Principal Officers |
|Nationality |
|(Indicate if Tax |
|Name Position Naturalized) Address A/C No. |
|_______________ ______________ _____________ _______________ ___________ |
|_______________ ______________ _____________ _______________ ___________ |
|_______________ ______________ _____________ _______________ ___________ |
|_______________ ______________ _____________ _______________ ___________ |
|_______________ ______________ _____________ _______________ __________ |
|_______________ ______________ _____________ _______________ ___________ |
| |
|(Please attach list of personnel authorized to transact with PEZA) |
|10. Type of Service and Service Rates: |
|(Please attach separate sheet if necessary) |
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|Service Rate |
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|11. Attach other documents as listed in checklist or standard application requirements |
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THE FOLLOWING DOCUMENTS ARE TO BE ATTACHED AS AN INTEGRAL PART OF THIS APPLICATION
1. DTI/SEC Certificate of Registration, Articles of Incorporation and By-Laws (if existing)
2. Anti-Graft Certificate, Republic Act No. 3019 (see attached)
3. Certificate of Official Filing of Application
4. Bio-data of Principal Officers
5. Audited Financial Statements for the last three (3) years, (for existing company)
Done in the City/Province of_______________________________________ this _______ day of _________________________________, __________ .
____________________
Affiant
___________________
Designation
Republic of the Philippines)
)S.S.
City/Province )
SUBSCRIBED AND SWORN to before me this ___ day of _________________, _____
in the City/Province of __________________________, Affiant exhibited to me his Community Tax Certificate No. ____________ issued at _____________________________________ on _______________________ , ____________ .
________________________
Notary Public
Until December 31,_______
Doc. No _____________
Page No._____________
Book No. ____________
Series of_____________
APPLICANT’S NOTARIZED UNDERTAKING
In applying for PEZA registration/accreditation, the applicant herewith makes the following representations and commitments:
1. The applicant is capable is operating on a sound and efficient basis and of contributing to the objectives of the Philippine Economic Zone Authority (PEZA) and to the development of the national economy in general. Its project is economically, and financially sound.
2. Applicant proposes to engage in good faith in creating a market for its services.
3. Applicant shall submit periodic reports and other information that the Authority may require on its activities in the Ecozone.
4. The applicant has read R.A. 7916, as amended, and the Rules and Regulation adopted by the PEZA and commits itself to abide by the provisions thereof and amendments thereto.
5. The applicant will start and operate the project covered by this application within such reasonable times as may be fixed by the Authority.
6. If the applicant is a corporation, the Board of Directors of applicant has authorized the filling of this application in accordance with the terms thereof.
7. That pursuant to the provision of Sec. 3 and Sec. 14 of R. A. 3019 (Anti-Graft Act), the applicant-enterprise has not given or promised to give and will not give any gift to any officer or employee of the Philippine Economic Zone Authority (PEZA) in connection with the filling and processing of this application.
8. That based on the records of the applicant no PEZA Board members or department Directors and or employee of the PEZA has an investment of any other financial interest, direct or indirect, in the applicant enterprise.
9. That there exists no dummy relationship between the stockholders or Directors of the applicant and any foreigner.
Done in the City/Province of _____________________________________ this ________ day of _________________________________, __________ .
_______________________
Affiant
_______________________
Designation
SUBSCRIBED AND SWORN to before me this ___ day of _______________, _____
In the City/Province of _________________________, Affiant exhibited to me his Community Tax Certificate No.__________ issued at _________________________________, on ___________________________, _______.
____________________________
Notary Public
Until December 31,____________
ANNEX A
ANTI-GRAFT CERTIFICATE
I, ________________________________________, of legal age, President/General
Manager of ________________________________________________ with postal address at _______________________________________________________________________
after having been duly sworn, dispose and say:
That pursuant to the provisions of Section 3 and 14 of R.A. 3019 (Anti-Graft and Corrupt Practices Act), the applicant enterprise, __________________________________ has not given or promised to give, and will not give, any gift in cash or in kind or any benefit to any officers, employees of the Philippine Economic Zone Authority (PEZA) in connection with the filing and processing of the application, nor will give such gift or benefit to any of said officers or employees after approval of its application.
That based on the records of the applicant, no Board Member or officer of the Philippine Economic Zone Authority has an investment or other financial interest, direct or indirect, in the business of the applicant; and
That this Certificate was made with the approval of applicant’s Board of Directors.
____________________
Affiant
SUBSCRIBED AND SWORN to before me this ___ day of ______________, ___
In the City/Province of ___________________________, Affiant exhibited to me Community Tax Certificate No. _________________ issued at ______________________________ on _________________________, __________.
______________________
Notary Public
Until December 31, ______
Doc. No. _____________
Page No. _____________
Book No. _____________
Series of______________
ANNEX B
CERTIFICATE OF OFFICIAL FILING OF APPLICATION
I, ______________________________________________, of legal age, Filipino, with address at _______________________________________________________________ depose and state:
That I am the President/General Manager of ________________________________
(the “Company”), a domestic corporation duly organized and existing under the laws of the Republic of the Philippines, with principal office at _________________________________, and I officially represent the company for purposes of filing of its application with PEZA for authorization to provide _______________________________________________ services to all PEZA-administered economic zones.
That the contents of the herein application filed with PEZA for registration/accreditation as an Ecozone Services Enterprise are true and correct to the best of my knowledge.
____________________
Affiant
SUBSCRIBED AND SWORN to before me this ___ day of ____________, ______
in the City/Province of _____________________________, Affiant exhibited to me Community Tax Certificate No. ____________ issued at __________________________ on ________________________, __________.
______________________
Notary Public
Until December 31, ______
Doc. No. _____________
Page No. _____________
Book No. _____________
Series of______________
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