Form No. O1- ALS, SLD, SOSIA (Revised August 2023) IRM IS FREE OF CHARGE AND CAN BE REPRODUCED) APPLICATION FORM FOR LICENSE TO OPERATE CoPrivate Security Agency Cicompany Guard Force Ci change of Business Name Dlwatenmen and Guard Services DSecurty K9 Services CiGovernment Security Force oe DProtective Services DiArmored Vehicle Secunty Services Ciceenes ieee Cprvate Detectwe Services CO) Security Hardware and Systems Gomtosec BUSINESS NAME EMAIL ADDRESS: BUSINESS ADDRESS: ‘CONTACT NUMBER: — NATURE OF OWNERSHIP: [_]SOUE PROPRIETORSHIP [|] JURIDICAL ENTITY __[_] GOVERNMENT ENTITY | INDICATE NUMBER OF BRANCHES (if any): Luzon Visayas ‘Mindanao NAME OF LICENSEE: ‘SO LICENSE NUMBER: [ VALIDITY: HOME ADDRESS: LONE WME . Administration/Operation LICENSE T | Security Manager Z __|_ Administrative Officer : ensioro 8. Board of Directors (FOR PARTNERSHIP/CORPORATION ONLY) Name. Position’ No. of Security Watchmen and Guard._ No.of Security Canine Handler/Canine Teams No.of Security Hardware and Systems Operator,_ No.of Securty Hardware and Systems Designer and No. of Company Security No. of Government Security Manager: Manager: No. of Bank and Armored Guard ‘No. of Company Security No. of Government Security No. of Protection Agent: ________| Officer: Officer: ‘No. of Company Security Guard No, of Private Detective No. of Security Officer, No. of Security Manager:__ No. of Security Consultant No. of Administrative and Operational Staff: No. of Government Security Guard: (No.of Metal Detectors: No. of Armored Vehicle. No. of Hand No. of Security Vehicle:___| peters No. of K9 Transport Vehicle:__ ee i ——t ‘Number of Years of Business Existence: LTO Number: Expiration Date: Trac hernaee/agency been charged criminaly/administratively/cilly in any court or quasi-judicial body within the Philippines? za ipCERTIFICATION | hereby certify that, all statements provided and documentary requirements attached herein are true, correct, valid and authentic and any misdeclaration/falsity stated therein shall be a basis for the cancellation/revocation of my License to Operate (LTO) without prejudice to the filing of criminal and/or civil case against me. | further certify that read and understand the provision under Rule Vl of the rights of the data sublect Sec 34 to 37 of Data Privacy Act of 2012 and | am voluntarily giving my consent on the use and processing of my personal data. Licensee SUBSCRIBED AND SWORN to before me this_ day of 2023, Applicant exhibit to me his/her CTC NO. issued in on , NOTARY PUBLIC Doc No: PAGE NO: BOOK NO: SERIES OF: