Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

Regional Office No. 1

REGISTRY OF ESTABLISHMENT

EIN: _____________________

1. Name of Establishment: ______________________________________________________________________________

2. Address: __________________________________________________________________________________________
Street City/Municipality Province
3. TIN: _________________________________
4. Telephone No. : _________________ Fax No: ____________ Email Address: __________________________________
5. Name of Manager/Owner _____________________________________________________________________________
6. Nature of Business & Product Manufactured, Service rendered or Merchandise sold:
(Example Manufacturing – Textile, Construction – Building, Agriculture – Production of Livestock, etc; Forestry – Logging;
Services – Generation and Distribution of Electricity, Commerce – Lumber and Construction Materials; Wholesale or Retail)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
7. Number of Employees
Total Filipinos Resident Non- Below 15 Below 15- 18-30 yrs. Above 30
Alien Resident 17 yrs. yrs.
Alien
Male
Female
Total
8. Name & Address of Labor Union, if any: __________________________________________________________________
9. Technical Information(Please Check / Enumerate)
10. 9a. Machinery, Equipment and Other Devices in use:
Circular saw Machine Drill Press Boiler Pressure Vessel Others, Specify _____________________
Engine Diesel Gasoline Internal Combustion Engine
9b. Materials Handling Equipment
Power Trucks Hand Trucks Conveyors Forklift Cranes Others, Specify ______________________
9c. Chemical or Substances Used or Handled: _____________________________________________________________
11. If Branch unit, name of parent establishment:______________________________________________________________
Location___________________________________________________________________________________________
12. Current Capitalization ________________________ Total Assets: ____________________________
13. Photocopy of SEC/CDA/DTI/NEA Certificate of Registration and Business Permit (pls. attach)

FOR RE-REGISTRATION ACCOMPLISH ALSO:

14. Past Application Number _______________________________ Date of Application: _______________
15. If Changing Name of Establishment, State Former Name; ____________________________________________________
16. If Changing Location, Give Past Address: _________________________________________________________________
17. Re-opening after previous closing (indicate Ceased Operation & Re-opening date): ________________________________
18. Change in Ownership (indicate previous owner & new mgt. effectivity date): ______________________________________

I hereby certify that the above information is true and correct.

________________________________________
Owner/President

Date Filed: __________ Date Approved: _________ Approved by: _________________________________

Regional Director