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APPLICATION FOR REGISTRATION/ACCREDITATION AS AN ECOZONE SERVICE ENTERPRISE (For Customs Broker, Freight Forwarder/Trucker and Security Agency)
APPLICATION FOR REGISTRATION/ACCREDITATION AS AN ECOZONE SERVICE ENTERPRISE (For Customs Broker, Freight Forwarder/Trucker and Security Agency)
PEZA Building, Roxas Boulevard corner San Luis Street, Pasay City
Metro Manila, Philippines
APPLICATION FOR REGISTRATION/ACCREDITATION
AS AN ECOZONE SERVICE ENTERPRISE
(For Customs Broker, Freight Forwarder/Trucker and Security Agency)
Date Filed _____________
O. R. No. _____________
Amount _____________
Name of Firm : ________________________________________________________________
Address : _____________________________________________________________________
_____________________________________________________________________________
Telephone No. : ____________________Fax No. ________________ E-mail ______________
Applicants Representative (Contact Person) to PEZA :
Name : ______________________________________________________________________
Address : ____________________________________________________________________
Telephone No. : __________________________ Fax No. ______________________________
Applicants Existing Business Entity, Registration (if any):
Office
Date
Securities and Exchange Commission (SEC)
________________
Department of Trade and Industry
________________
Bureau of Customs (BOC)
________________
Others, please specify __________________
________________
Registration No.
_________________
_________________
_________________
_________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
Project Summary:
1. Brief Description of the Project (Describe operations, services to be provided in the zone,
arrangement, etc.)
No.
Subscribed
Amt. P % Total
1. Filipino
2. Non-Filipino
a.
b.
c.
d.
e.
Total
6. Capital of Partners or Single Proprietor
Nationality
(Indicate if
Naturalized) Residence
Name
Capital
No.
% of
Firms
Total
Paid-Up
Amt. P
% Total
Tax
A/C
No.
Name
________________________
________________________
________________________
________________________
Location/Address
__________________________
__________________________
__________________________
__________________________
Product/Service
____________________
____________________
____________________
____________________
Name
Tax
A/C No.
No. of
Shares
Name
Tax
A/C No.
9. Principal Officers
Name
_______________
_______________
_______________
_______________
_______________
_______________
Position
_______________
_______________
_______________
_______________
_______________
_______________
Nationality
(Indicate if
Naturalized)
______________
______________
______________
______________
______________
______________
Residence
_______________
_______________
_______________
_______________
_______________
_______________
Tax
A/C No.
___________
___________
___________
___________
___________
___________
Rate
OF THIS APPLICATION
1.
2.
3.
4.
5.
ANNEX
ANTI-GRAFT CERTIFICATE
I, _________________________________________, of legal age, President/General
Manager of ___________________________________________________ with postal address
at ____________________________________________________________________________
after having been duly sworn, depose and say:
That pursuant to the provisions of Section 3 and 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 officers, employees of the Philippine
Economic Zone Authority (PEZA) in connection with the filing and processing of this
application, nor will give such gift 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
applicant; and
That this certificate was made with the approval of applicants board of directors.
___________________________
Affiant
___________________________
Notary Public
Until December 31, ___________
Doc. No. _____________
Page No. _____________
Book No. _____________
Series of _____________
ANNEX
___________________________
Affiant
___________________________
Notary Public
Until December 31, ___________
Doc. No. _____________
Page No. _____________
Book No. _____________
Series of _____________