Department of Agriculture FORM A

Agribusiness and Marketing Assistance Service (AMAS)

KADIWA AGRIBIZ PORTALSUPPLIER’S PARTICIPATION

GENERAL INFORMATION
FORM
Registered Enterprise Name/ YAKAP AT HALIK MULTI-PURPOSE COOPERATIVE BATANGAS 2
Name of Registered
Farmer/Fisherfolk
Business Address BRGY. BAGUMBAYAN, TANAUAN CITY, BATANGAS
Farm Location PANTAY MATANDA, TRAPICHE,TANAUAN CITY, POB.1, SAN MIGUEL, SAN VICENTE, STO.
TOMAS, BATANGAS
Name of Contact Person JULIETA G. VERGARA
Designation/ Position CHAIRMAN
Email Address yandmpcb2@yahoo.com
Tel. Nos.
Mobile Nos. 0942 274 7527 / 0917 365 6021
Type of Registration RSBSA DTI SEC ✘ CDA DOLE Others, pls specify: __________
Registration Number
OR 9520-04001256
Reference/Control Number
(for those enrolled in
RSBSA)

Supply Information (please use separate sheet if necessary)

Agriculture Specifications Available *Selling Source of Supply Months Status
and Fishery (e.g. for fresh Volume Price per Please indicate available (please click applicable box
Commoditie produce, indicate for Sale Unit whether: a) Own and indicate date)
s/ Products type or variety; for (Php) Production; b)
Available processed (indicate Individual Farmers; c)
for Sale products, price and Producer groups; d)
indicate unit Traders; or e) Others
packaging used) e.g. Consolidator;
description, size, Wholesaler;
etc.) Assembler, etc.
SUGAR CANE FRESH PRODUCE 900 Tons Php Produced by individual Dec - Jan ✘ Available
2,500.00 farmers who are Not available
per ton Cooperative members As of (please indicate date):
Dec 2021 – Jan 2022
MAIS FRESH PRODUCE 52,000 – Big – Php Produced by individual August - ✘ Available

65,000 7.00 per farmers who are September Not available

PIECES piece Cooperative members As of (please indicate date):
Small – August - September 2021
Php 5.00
per piece
PECHA FRESH PRODUCE 1 TON Php 65.00 Produced by individual August - Available
Y per kilo farmers who are September Not available
Cooperative members As of (please indicate date):
August - September 2021

MUSTASA FRESH PRODUCE 1 TON Php 65.00 Produced by individual August - Available
per kilo farmers who are September Not available
Cooperative members As of (please indicate date):
August - September 2021

*Indicated prices are as of (please indicate date): March, 2022

Note: If you are engaged in production of agri-fishery commodities/ products, please fill-up the attached Production and Harvest
Schedule (Form B1.A)
Delivery Arrangements
Frequency of delivery (i.e. daily, weekly, Daily
twice a week, etc.)
Minimum volume per delivery
Mode of Delivery (please click applicable ✘ Pick-up at your farm/ designated pick-up area (please specify pick-up address/

box) location): _Pantay Matanda, Trapiche (TANAUAN) & Pob. 1, San Miguel, San
Vicente, (STO. TOMAS,BATANGAS
✘ Deliver to buyer (please click applicable box):

✘ At any area/ location identified by the buyer

Within specific area/ location only (please specify up to what area):

___________________
Other mode (please specify): _______________________________

Transportation/ Delivery Services (please click applicable box)

Owned ✘ Hired None No. of vehicle: _______
 Type of Vehicle (e.g. closed van, truck, etc) Capacity With Food Pass (YES/NO)
Sugar Cane (10-wheeler truck) - hired 1 truck = 20 tons YES
Fruits & Vegetables (6-wheeler truck) - hired 1 truck =5-6 tons YES
DA Projects/ Programs interested in (please click applicable box)
✘ KADIWA ni Ani at Kita Project Capable to conduct retail selling in Metro Manila
✘ Capable to conduct retail selling within the province/ region only

Other projects/ programs Please specify:

______________________________________________

I hereby declare that all information indicated above are true and correct, and that they may be used by the Department of Agriculture for the
purposes of inclusion in the DA KADIWA Agribiz Portal without violating the Data Privacy Law.
_ JULIETA G. VERGARA
Printed Name and Signature of Authorized Representative
Date: __________________________
Supply Information (please use separate sheet if necessary)
Agriculture Specifications Available *Selling Source of Supply Months Status
and Fishery (e.g. for fresh Volume Price per Please indicate available (please click applicable box
Commoditie produce, indicate for Sale Unit whether: a) Own and indicate date)
s/ Products type or variety; for (Php) Production; b)
Available processed (indicate Individual Farmers; c)
for Sale products, price and Producer groups; d)
indicate unit Traders; or e) Others
packaging used) e.g. Consolidator;
description, size, Wholesaler;
etc.) Assembler, etc.
BANANA FRESH PRODUCE 40,000 Php 45.00 Produced by individual Dec – June ✘ Available
(LACATAN & KILOS per kilo farmers who are Not available
SABA) Cooperative members As of (please indicate date):
Dec 2022 – Jan 2023
AMPALAYA FRESH PRODUCE 25,000 Php 60.00 Produced by individual August - ✘ Available

KILOS per kilo farmers who are September Not available

Cooperative members As of (please indicate date):
August - September 2022

OKRA FRESH PRODUCE 800 KILOS Php 45.00 Produced by individual August - Available
per kilo farmers who are September Not available
Cooperative members As of (please indicate date):
August - September 2022

SWEET FRESH PRODUCE 1 TON Php 65.00 Produced by individual August - Available
POTATO per kilo farmers who are September Not available
Cooperative members As of (please indicate date):
August - September 2021

INSTRUCTIONS HOW TO FILL-UP THE KA-ISA SUPPLIER’S PARTICIPATION FORM (FORM B1):

ITEM INSTRUCTIONS/ DEFINITION

Registered Enterprise Name/ Name of For registered enterprises, indicate your registered name based on your Certificate of
Registered Farmer/Fisherfolk Registration issued to you either by DTI/SEC/CDA/DOLE, etc.

For individual farmers/ fisherfolk, indicate your complete name enrolled/ registered in
the Registry System for Basic Sectors in Agriculture (RSBSA).
Business Address Indicate address of the main office of the enterprise.
Farm Location For individual farmers/ fisherfolk and those enterprises engaged in production of agri-
fishery commodities/products, please indicate the complete farm location (sitio/purok,
barangay, town, province).
Name of Contact Person Indicate the complete name of the contact person.

Contact person is any representative authorized to provide information and enter into
transaction.
Designation/ Position Indicate the contact person’s designation/ position title.
Email Address Indicate the official e-mail address of the enterprise/ farmer/ fisherfolk.
 Tel. Nos. Indicate the official telephone number of the enterprise/ farmer/ fisherfolk. Indicate
also the alternative telephone number, if there is any.
Mobile Nos. Indicate the official mobile number of the enterprise/ farmer/ fisherfolk. Indicate also
the alternative mobile number, if there is any.
Type of Registration Tick/click applicable type of registration. This portion also considers the enrollment/
registration with RSBSA.
Registration Number For registered enterprises, indicate the registration number based on your Certificate
of Registration issued by DTI/SEC/CDA/DOLE, etc.
For those enrolled/ registered with RSBSA, please indicate the reference/control
number as appeared in your RSBSA enrollment form/registration form/stub.
Supply Information:
a. Agriculture and Fishery List down all agri-fishery commodities/ products that you are selling/supplying. This
Commodities/ Products portion should be similar with what you have ticked/clicked or indicated in the Form A
Available for Sale under “Agriculture and Fishery Commodities/ Products”.
b. Specifications For fresh produce, please indicate specific type or variety. For processed products and
other products, indicate packaging description, size and other description and
specifications.
c. Available Volume for Sale Indicate volume of agri-fishery commodities/ products available for sale.
d. Selling Price Indicate the current selling price on the day that you are filling-up the form. Please take
note that the selling price is subject to change and can be updated as frequent as
possible.
e. Source of Supply This refers to the source/s of commodities/products being sold. For this portion, you
may have multiple choices. Please type appropriate source/s of supply based on the
options and do not just type letters (i.e. A, C). If “Others”, please specify particular
source/s. See sample input below:

Sample 1: Own production

Sample 2: Own production; Producer groups; Traders
f. Months available Indicate specific months your commodities/products will be available. You may
indicate all specific months or you may also indicate it in range. See sample input
below:

January, February, March, April OR January-April

g. Status Click/ tick applicable box. This portion will determine the availability of your
commodities/ products. If you ticked/ clicked “Available”, it means that the particular
commodity/ product is still available for sale. On the other hand, if you ticked/ clicked
“Unavailable”, it means that the commodity/ product is no longer available. This
portion can be updated as frequent as possible, thus, it is important to also indicate the
reference date when updating.
*Indicated prices are as of Indicate date (month, day and year). This will be the basis in determining the validity of
_________________ prices indicated in the Supply Information table under “Selling Price”. This is in
consideration of the fact that prices are subject to change and can be updated as
frequent as possible.
Delivery Arrangements
a. Frequency of delivery Indicate the frequency of delivery (i.e. daily, weekly, twice a week, etc.)
b. Minimum volume per Indicate the minimum volume that you will require for you to deliver.
delivery
c. Mode of delivery Tick/ click applicable mode of delivery. If you ticked/ clicked “Pick-up at your farm/
designated pick-up area”, please specify particular address/ location for reference of
interested buyer. If you ticked/ clicked “Deliver to buyer”, please indicate whether at
any area/location identified by the buyer or within specific area only. If within specific
area only, please specify up to what area only. If “Others” , specify the particular mode.
Transportation/ Delivery Services Tick/ click applicable box/es whether “Owned”, “Hired” or “None”.
a. Type of Vehicle Indicate/ list down the types of vehicle that you are currently using for your enterprise
operation (i.e. closed van, truck, etc.). Indicate the corresponding capacity of each
vehicle. On the third column of the table, indicate whether the vehicle has been issued
with food pass or not. If issued with food pass, type “YES”. If not, type “NO”.
DA Projects/ Programs interested in Tick/ click the DA Projects/ Programs that you are interested to participate in. If you
ticked/ clicked “Other projects/ programs”, please indicate particular project/
programs.

Note: Prior to signing, make sure that you have read the statement at the bottom portion of the form, to wit:
“I hereby declare that all information indicated above are true and correct, and that they may be used by the Department of Agriculture for the
purposes of inclusion in the DA KADIWA Agribiz Portal without violating the Data Privacy Law.”