JICA - 国際協力機構



JICA Form 1 (1/5)

　　Applicant No. ___

APPLICATION FORM FOR JICA SUPPLIER REGISTRATION

Please enter information in the appropriate column.

|1. Business Information * indicates a required section/ field |

| | |

|Registered Business/ Trade / Company Name | |

|Business/ Mailing Address (attach location sketch) | |

|(P.O. Box not allowed) | |

| | |

|Main office: | |

|Street address: |____________________________________________ |

|City: |____________________________________________ |

|Province/ Region: |____________________________________________ |

|Zip/ Postal Code: |____________________________________________ |

| | |

|Branches: | |

|Street address: |____________________________________________ |

|City: |____________________________________________ |

|Province/ Region: |____________________________________________ |

|Zip/ Postal Code: |____________________________________________ |

| | |

|Contact Numbers | |

|Telephone Number(s): |____________________________________________ |

|Fax Number: |____________________________________________ |

|Mobile Number: |____________________________________________ |

| | |

|Email address: |____________________________________________ |

| | |

|Website: |____________________________________________ |

|2. General Information* |

|a. General Business Information | |

|SEC/DTI/CDA Business Registration Number and Date | |

|Year Business was Established | |

|Form of Ownership |□ Single Proprietorship |

| |□ Foundation |

| |□ Partnership |

| |□ Corporation |

| |Others (specify) |

| |______________________ |

|Capitalization [1] |Authorized Capital ___________ |

| |Subscribed Capital ___________ |

| |Paid up Capital ______________ |

|Type of Supplier as registered with SEC or DTI |□ Manufacturer □ Retailer |

| |□ Producer □ Exporter |

| |□ Service □ Importer |

| |□ Wholesaler □ Exclusive Distributor |

| |□ Trading House/ Company |

| |Others _________(specify) |

|BIR TIN Number | |

|BIR VAT Registration Number | |

JICA Form 1 (2/5)

|b. Primary Contact Information* | |

|Name of Officers: | |

| | |

|President |_____________________________________ |

|Secretary |_____________________________________ |

|Treasurer |_____________________________________ |

|Name of Authorized Representative | |

|Official Title/ Position | |

|Telephone number |_____________________________________ |

|Mobile number |_____________________________________ |

|Fax number |_____________________________________ |

|Email Address |_____________________________________ |

|Current Number of Full time Employees |Type of Employees |No. of |

| | |employees |

| |Management | |

| |Administrative | |

| |Sales | |

| |Technical/ Operations | |

| |Others, specify | |

| |Total | |

|Principal Products/ Services | |

|(Please refer to Attachment 1. Please use additional |Products/Services |

|sheets if necessary) | |

| | |

| | |

| | |

|Names and addresses of parent company, subsidiaries or | |

|associated companies with whom there is collaboration or | |

|joint venture, if any: | |

| | |

|Name of Company |Address |

|________________________________________ |________________________________________ |

|________________________________________ |________________________________________ |

|________________________________________ |________________________________________ |

|3. Financial Information* |

| |Most Recent Financial Year |Prior Financial Year |

| |(e.g. 2018) |(e.g. 2017) |

|Net Worth or Total Stockholder’s Equity | | |

|Net Sales | | |

|4. References and Transaction Record |

|(Please indicate names, address, telephone/ fax numbers, email address, and contact persons; references may be contacted by JICA |

|Philippine Office) |

|Name of Bank (s) & | Contact Name |Telephone No. & Fax |Email Address |

|Address | |No | |

| | | | |

| | | | |

JICA Form 1 (3/5)

I do hereby certify that I have the authority to prepare and submit this supplier registration and that the information provided is true and correct. I hereby acknowledge that the JICA Philippine Office Terms and Conditions will be used as basis for any and all contracts.

| |

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|____________________________________________________ |

| |

| |

| |

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|Date: _______________________________________________ |

Attachment to JICA Form 1 (4/5)

Instruction to Supplier Applicant:

Please specify major business activity (ies) and products/ goods being offered by your company.

Name of Supplier Applicant: __________________________________________________________

|Business Activity |Products/ Goods |

|Agriculture | |Agricultural machinery & equipment |

| | |Agricultural products |

| | |Agricultural services |

|Construction | |Construction of buildings, etc. |

| | |Construction of roads, bridges, etc. |

| | |Construction materials |

| | |Construction services |

|Cultural & recreation services | |Arts |

| | | Parks |

| | | Gardens |

| | | Services to the arts |

| | |Books |

| | | Books |

| | | Maps |

| | | Other publications |

| | |Sports & recreation |

| | | Sports products |

| | | Equipment |

| | | Services |

|Dental supplies & equipment | |Dental supplies |

| | |Dental equipment |

|Electricity, gas, and water | |Electricity |

| | |Gas |

| | |Water supply |

| | |Sewerage services |

| | |Drainage services |

| | |Chemicals & chemical products |

|Electronics | |Computers |

| | |Computer accessories |

| | |Computer components |

| | |Computer input devices |

| | |Computer software |

| | |Business & productivity |

| | |Communications |

| | |Developer tools |

| | |Graphics & publishing |

| | |Operating systems |

| | |Reference |

| | |Utilities |

| | |Computer storage devices & media |

| | |Computer systems |

| | |Control and instrumentation, instruments/ equipment |

Attachment to JICA Form 1 (5/5)

|Business Activity |Products/ Goods |

|Electronics (continuation) | |Electrical supplies/accessories |

| | |Automotive electronics |

|Firefighting, rescue & safety equipment | | |

|Office furniture and fixtures | | |

|Office devices & supplies | | |

|Information & communications technology | |Information technology services & IT enabled services |

| | |Information technology parts, accessories & peripherals|

|Janitorial equipment & supplies | | |

|Maritime/ Navigational & Railway equipment | | |

|Medical supplies, laboratory instruments & medical | |Medical supplies |

|equipment | | |

| | |Laboratory instruments |

| | |Medical equipment |

|Mining and quarrying | |Mining |

| | |Extraction |

| | |Exploration |

| | |Coal |

| | |Oil |

| | |Gas |

| | |Metallic |

| | |Non - metallic |

| | |Quarrying |

|Pharmaceuticals | | |

|Telecommunications, communications, and radar | |Communications & communication services |

| | |Cellular phones, cards, accessories |

| | |Internet service providers |

| | |Postal services |

| | |Courier services |

| | |Telecommunications services |

|Transport & storage services | |Transport |

| | |Air |

| | |Road |

| | |Water |

| | |Rail |

| | |Storage |

|Vehicles, vehicle parts, accessories & components | |Vehicles |

| | |Vehicle parts, accessories & components |

| | |Vehicle repairs & services |

|Wholesale & retail trading | |Wholesale trading |

| | |Retail trading |

|Water treatment, equipment & products | | |

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[1] The information is reflected in the Supplier’s SEC Registration Papers/ Articles of Incorporation or the DTI Business Registration Papers.

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