JICA Form 1 (1/5)
Applicant No. ___
APPLICATION FORM FOR JICA SUPPLIER REGISTRATION
1. Business Information * indicates a required section/ fieldRegistered 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:
Web site: / ______
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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)
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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)
Name of Officers:
President
Secretary
Treasurer / ______
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Name of Authorized Representative
Official Title/ Position
Telephone number
Mobile number
Fax number
Email Address / ______
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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 sheets if necessary) / Products/Services
Names and addresses of parent company, subsidiaries or associated companies with whom there is collaboration or joint venture, if any:
Name of Company
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3.Financial Information *
Most Recent Financial Year
(e.g. 2010) / Prior Financial Year
(e.g. 2009)
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) &
Address / Contact Name / Telephone no. & Fax No / Email Address
JICA Form 1 (3/5)
I do hereby certify that I have the authority to prepare and submit this supplier registration and at 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.
______Signature
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Name
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Official Designation
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/ GoodsAgriculture / 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)
Electronics (continuation) / Electrical Supplies/Accessories
Automotive Electronics
Fire fighting, 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 Equipment / Medical Supplies
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
[1] The information is reflected in the Supplier’s SEC Registration Papers/ Articles of Incorporation or the DTI Business Registration Papers.