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: www.peza.gov.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:
4. Financial Institutions from which the Applicant Intends to Obtain Financing:
Bank References:
5. Capital Structure- For Corporations Only (Value in Peso)
Common Stock Authorized No. Amount (PhP) Par
______
1. Filipino
a.
b.
c.
d.
e.
2. Non-Filipino
Total / Subscribed / Paid-Up
No. / Value / % to Total / No. / Value / % to Total
6. Capital of Partnership or Single Proprietor
Nationality % to Tax
(Indicate if Firm’s A/C
Name Naturalized) Address Capital Total No.
7. Business Activities Other Than Those Covered by Application
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.
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)
Service Rate
11. Attach other documents as listed in checklist or standard application requirements
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______