PCAB Form No - DOC - DOC by ePvf9c4b

VIEWS: 142 PAGES: 17

									                                                                            PCAB Form No. 101

                                         APPLICATION FOR NEW CONTRACTOR'S LICENSE
                                   with the PHILIPPINE CONTRACTOR'S ACCREDITATION BOARD
The following pertinent documents and information are to be submitted in support of the license application of said firm:

  Checklist for New License Application
   A. Legal
   [ ] 1. General Information (PCAB Form Nos. 101a and 102);
            [ ] 1.1  For Sole Proprietorship: Certified true copy of BTRCP Certificate of Registration with the pertinent
                      BTRCP Form No. 16;
                    For Partnership or Corporation: Certified true copy of SEC Certificate of Registration and Articles of
                      Partnership/Incorporation and By-Laws showing Construction as the primary purpose or one of the purposes
                      and subsequent amendments thereto;
   [ ] 2. Authorized Managing Officer (AMO) Nomination:
          [ ] 2.1 AMO Affidavit (PCAB Form No. 103) with a passport size picture of AMO;
                  For corporations only: Original Corporate Secretary's certificate as to the nomination of the AMO
                    (PCAB Form No. 104);
          [ ] 2.2 Original NBI clearance of Filipino AMO;
          [ ] 2.3 If AMO is Non-Filipino (in addition to 2.1):
                   [ ] 2.3.1 Valid Working visa
                   [ ] 2.3.2 Alien Certificate of Registration;
                   [ ] 2.3.3 NBI clearance if AMO has resided in the Philippines for six (6) months or longer if not,
                            equivalent clearance from AMO's home country duly authenticated by the Philippine embassy.
   Note:         For Corporations or Associations with foreign shareholders, the following documents must be submitted
           a.    Corporate Secretary’s certifications as follows:
                 1. List of stockholders showing their nationalities and shareholdings; and
                 2. List of Board of Directors showing their names and nationality.
           b.    Copy of latest General Information Sheet duly filed with SEC showing the names of stockholders and directors, nationality
                 and shareholdings
   B.       Financial
   [ ] 3. Financial Statements (duly audited and signed on each page by a PRC-BOA accredited external auditor) and a
           diskette / CD (compact disc) containing the firm’s Audited Balance Sheet & Income Statement in the prescribed template
          (PCAB Financial Statement Forms A & B downloadable from the DTI website at www.business.gov.ph together with the
           pertinent application forms) to be submitted with the following supporting documents, if applicable:
           [ ] 3.1 For old companies, copy of the Quarterly or Annual Income Tax Return certified true by the BIR,
                   covering the income reported in the Audited Income Statement submitted for the quarter or taxable
                   year immediately preceding the filing of application, whichever is applicable;
           [ ] 3.2 Original copy of Bank Certification/Bank statement of account certified by Bank Manager of cash
                   deposits as of the Balance Sheet date;
                    [ ] 3.2.1 Authorization to Depository Bank (PCAB Form No. 105);
           [ ] 3.3 List of Land and Building/s owned by the company and registered in its name (PCAB Form No. 106a);
                    [ ] 3.3.1 Certified true copy of TCT including back page;
                    [ ] 3.3.2 Deed of Sale or Certified True Copy of Tax Declaration of Land/Building owned by the firm.
           [ ] 3.4 List of Construction and/or Transportation/Delivery Vehicles/Equipment/Machineries/Plants
                   owned by the company and registered in its name (PCAB Form No. 106b);
                      [ ] 3.4.1 Certified true copy by the LTO of the LTO Certificate of Registration and current Official Receipt of
                                Registration of registrable Construction and/or Transportation / Delivery Vehicles / Equipment reported;
                      [ ] 3.4.2 Certified true copy of deed of sale or sales invoices/official receipts for non-registrable construction
                                equipment/machineries/plants;
     [ ] 4. Authorization to BIR & other agencies (PCAB Form No. 105a);
   C. Technical
   [ ] 5. List of Sustaining Technical Employee/s - STE (PCAB Form No. 106c) supported by the following documents
          for each STE:
           [ ] 5.1. STE Affidavit/s (PCAB Form No. 108) with a passport size picture/s of the nominated STE/s;
                    [ ] 5.1.1 Certified true copy by PRC of valid PRC ID of STE as licensed professional or original
                              Certification of Good Standing from PRC;
                    [ ] 5.1.2 Original NBI Clearance/s of newly nominated STE/s;
           [ ] 5.2 STE Affidavit/s of Construction Experience (PCAB Form No. 109);
           [ ] 5.3 Personal Appearance Form duly accomplished and signed by the STE/s appearing before the designated officer of the
                   PCAB or the nearest DTI regional/provincial office (PCAB Form No. 110)
   D.     Others: PCAB Response Form (self-addressed and with sufficient stamps affixed)
   NOTE: Original Signature of AMO on each and every page of the application forms including supporting
         documents (except item 5.3)
            The Board may require the AMO interview and submission of pertinent documents/information other than the above
             in order to fully determine the qualifications of the applicant;
            AMO / Applicants for TRADE category may no longer be required to take the AMO examination.
            Photocopies of documents, in lieu, of certified copies are accepted provided the original copies are presented for
             authentication
     DO NOT FILL (For PCAB use only)
     Total No. of Pages Submitted: _______                                         Checklisted by: ________________________________
     [ ] Self-stamped envelopes * (no. ______ )                                                      Signature Over Printed Name/Date
     Remarks: ____________________________________                               _______________________________________
  _________________________________ ___________________________________
   * One for each depository bank; one each for BIR, LTO, & LRA; and one for each vendor of non-registrable construction equipment reported
  Applicants interested to participate in government projects should accomplish Form. No. 601 (Application for Registration and Classification of Government Projects) and file the
  same together with the PCAB Application Form.
  Revised 01/22/07
                                                                                 PCAB Form No. 101a




In behalf of ____________________________________________________________,
                          (Name of Firm)

I hereby request that its application for Contractor's License be approved.

I hereby certify to the completeness of the information/documents contained in this
application appertaining to the category/classification the company is applying for
and that they are true and correct.

I am fully aware that:
1. all documents submitted in support of this application are subject to verification
   before PCAB action;
2. any discovered misrepresentation of information and/or manifestations of fraud
   on the application documents submitted by my firm applicant or its Authorized
   Representative/Agent/Liaison Officer shall be subjected to investigation which
   may result to the disapproval of my application, denial/suspension/revocation
   of license and blacklisting of my firm and myself as its Authorized Managing
   Officer; and
3. unconfirmed information/documents submitted to support my firm's
   qualifications will be excluded for categorization/classification purposes.
4. the evaluation of my application's qualification shall be solely based on the
   documents submitted at the time the application was filed/accepted by PCAB.




                                              _______________________________
                                                Authorized Managing Officer
                                                 (Signature over Printed Name)



Republic of the Philippines)
______________________)S.S.

SUBSCRIBED AND SWORN TO before me this ________ day of ___________________ 20____ at
______________________; affiant exhibited to me his Community Tax Certificate No. _______________
issued at __________________ on _________________ 20 ___.


DOC. NO. _______________;
PAGE NO._______________;
BOOK NO._______________;                                __________________________
                                                              NOTARY PUBLIC
                                                          (Until December 31, _______)
                                                                                         PCAB Form No. 102



                                      GENERAL INFORMATION
A. CONTRACTOR’S IDENTIFICATION
 Name of Firm:


 Office Address:                                                                  Tel./Fax No.:


 If Provincial based, contact address in Manila, if any:                          Tel./Fax No.:


 Website:                                                     E-mail Address:


 Type of Organization (Please Check):.
           [ ] Corporation   [ ] Partnership      [ ] Sole Proprietorship       [ ] Joint Venture
 SEC/BTRCP Registration No.:        Date of Registration:                        SEC/BTRCP Expiry Date:

 SSS Employer’s I.D.No.:                                      Tax Identification No.:

   CATEGORY                                         CLASSIFICATION/S
  APPLIED FOR       APPLIED FOR:         Principal Classification:
                                         Other Classification/s :
 ______________

B. OWNERS/STOCKHOLDERS/OFFICERS* (For Corporation, Partnership and Joint Venture)
                                                                      Capital     Paid-Up
            Name                 Position          Nationality Subscription       Capital




C. AFFILIATION WITH OTHER LICENSED CONTRACTORS

                     Name of Affiliated Firm                                      Nature of Affiliation




Revised 03/31/04


                                                           CERTIFIED CORRECT BY:


                                                   ____________________________________
                                                         Authorized Managing Officer
                                                              (Signature over Printed Name)
PCAB Form No. 103
                                                                                                    Passport size
                                                                                                     Picture of
                                                                                                       AMO
Republic of the Philippines )
Province of ______________           )
Municipality of ___________          ) S.S.

                                                    AMO AFFIDAVIT
       I, __________________________________________________________________________________________,
              LAST NAME                       FIRST NAME                     COMPLETE MIDDLE NAME
Filipino, of legal age, born on ____________________________________________________________ single/married
to ________________________________________________________________________________________________
              LAST NAME                       FIRST NAME                     COMPLETE MAIDEN NAME
and residing at __________________________________________________________________________ having duly
sworn in accordance with law depose and say:
1. That I am the Authorized Managing Officer (AMO) of ________________________________________ empowered
   to render general management and administrative decisions.
2. That I possess the following educational qualifications:
                                                                                                        INCLUSIVE DATES
        NAME OF SCHOOL                         ADDRESS                       DEGREE EARNED              OF ENROLLMENT




3. That I possess at least two (2) years of experience in the construction industry as follows (Sec. 20, R.A. 4566):
                            COMPANY/                                                                           DATES OF
        POSITION        NATURE OF BUSINESS            ADDRESS                   JOB DESCRIPTION              EMPLOYMENT




   (use additional sheet if necessary)
4. That I possess knowledge of the building, safety, health , & lien laws of the Republic of the Philippines & the
   rudimentary administrative principles of construction contracting from my work experiences in item 3 above and
   from the following training/seminars (Sec. 20, RA 4566):

                                                                                                        INCLUSIVE DATES
           TRAINING/SEMINAR                   CONDUCTED BY                      ADDRESS                   OF TRAINING




5. That I am not involved in any construction malperformance suggestive of negligence, incompetence or malpractice or
   any act of omission liable for disciplinary action by myself or in collaboration with any other person (Rule 4, Section
   4.2)
6. That I have not been convicted by a court of competent jurisdiction of any offense involving moral turpitude (Rule 4,
   Section 4.2)
7. That I am fully aware that my failure to notify PCAB of my disassociation with my present employer shall cause my
   disqualification to be an Authorized Managing Officer, a Sustaining Technical Employee or a license applicant with
   PCAB (For corporations and partnerships only)
8. That I authorize the PCAB to verify and investigate any or all information in this instrument from whatever sources
   PCAB may consider appropriate;
9. That I certify under pain of perjury that all information on this affidavit are true and correct.
       FURTHER AFFIANT SAYETH NAUGHT.
                                                                    _________________________________
                                                                                  Affiant

    SUBSCRIBED and sworn to before me this _____ day of _________________, 200 ___ affiant exhibited his/her
Community Tax Certificate No. __________ issued at _____________________ on ________________.
Doc. No. __________;
Page No. __________;
Book No. __________;                                                             Notary Public
Series of 200 __.                                                            Until December 200__
                                                                                              PCAB Form No. 104


For Corporations Only

                                                   AMO NOMINATION

        I ____________________________________________________, Filipino, of legal age, single/married and residing at
-____________________________________________________________ do hereby certify, in my capacity as the duly elected
and incumbent Board Secretary of __________________________________________________________________________,
                                                                   (Name of Firm)
that during the regular board/partners' meeting held on ___________________ wherein a quorum was present, the following
resolution was unanimously approved, to wit:

               "R E S O L V E as it is hereby resolved that
               _________________________________________________________________,
                       (Surname,               First Name,                 Middle Name)
               a senior executive who has been granted the power to render general management and
               administrative decision, be appointed as the firm's authorized sole management
               representative to act on all matters concerning the requirements of the PCAB and
               implementation of R.A. 4566 as amended by P.D. 1746."
       In WITNESS WHEREOF, I have hereunto affixed my hand this ______________ day of ___________________
200___, in ______________________________, Philippines.



                                                 _________________________________
                                                           Board Secretary
                                                        (Signature Over Printed Name)

       SUBSCRIBED and sworn to before me this ________ day of   ______________________________________          at
__________________________________________________, affiant exhibited to me his/her Community Tax Certificate. No.
____________ issued on _________________________ at ______________________________________________.



Doc. No.       __________
Page No.       __________
Book No.       __________
Series of 200 __.                                               NOTARY PUBLIC
                                                                Until December 200 ____




Revised 03/31/04
                                                                                      PCAB Form No. 105




THE MANAGER
_________________________________
_________________________________
_________________________________


Subject: Account # _______________________

Sir:

Please provide the Philippine Contractors Accreditation Board (PCAB), a government agency under the
Department of Trade and Industry, any information they need regarding the subject account with your bank.

I am applying for a contractor's license from PCAB and part of their evaluation process is the verification of
bank deposits and other assets of an applicant.

This will serve as your authorization to release any information that may be requested by PCAB regarding the
above subject account.

 Thank you.


                                                    Very truly yours,


                                           ___________________________________
                                                Signature over Printed Name


                                           __________________________________
                                                   Company Name


                                           ___________________________________
                                                        Date



Note: To be submitted in two (2) copies.




Revised 03/31/04
                                                                                         PCAB Form No. 105a




                                                AUTHORIZATION


                   The Philippine Contractors Accreditation Board (PCAB) is hereby authorized to verify
      and secure information and/or copies of documents submitted by or in the name of the firm to any or all
      of the following agencies relative to its application filed with the PCAB:

                         1.   Bureau of Internal Revenue
                         2.   Securities and Exchange Commission
                         3.   Land Registration Authority
                         4. Land Transportation Office
                         5. Social Security System




                                                Name of Applicant Firm


                                                _____________________________________


                                                By:

                                                 _____________________________________
                                                 Signature over Printed Name of Proprietor
                                                 or Authorized Managing Officer


                                                Date: _________________________________




Revised 03/31/04
                                                                                                PCAB Form No. 106a




    A. LIST OF LAND, BUILDING AND OTHER IMPROVEMENTS OWNED BY AND REGISTERED IN
       THE NAME OF THE COMPANY AS OF THE BALANCE SHEET DATE


             COMPLETE                 TCT/CCT            LOCATION                 ACQUISITION   ACQUISITION
           DESCRIPTION                NUMBER          (St. #, Barangay,              COST          DATE
        (Type of land/building                    Municipality/ City, Province)
              and area)




    May be reproduced if necessary                                                                Revised 03/31/04




                                     _________________________________________
                                         Signature over Printed Name of AMO


                                     _________________________________________
                                                 Company Name


                                     _________________________________________
                                           PCAB License No. (If applicable)


                                     ________________________________________
                                                  Date Signed




CFY ___________________
Type of Application: (Pls. check)
-

             New
             Upgrading
             Renewal
             Others, pls. specify
                _______________________
                                                                                           PCAB Form No. 106b


B. LIST OF DELIVERY AND TRANSPORTATION EQUIPMENT OWNED BY AND REGISTERED IN THE
   NAME OF THE COMPANY ASOF THE BALANCE SHEET DATE

                 COMPLETE DESCRIPTION                              ACQUISITION             BOOK
                                                                                             VALUE
    Plate       Chassis          Engine     M.V. File     CR No.   Date         Cost
     No.          No.             No.         No.

                                                                                P          P




 TOTAL                                                                          P          P

LIST OF MACHINERIES/PLANTS AND OTHER CONSTRUCTION EQUIPMENT OWNED BY THE
COMPANY AS OF THE BALANCE SHEET DATE

         COMPLETE                                                      ACQUISITION             BOOK
                                            SERIAL NO.
        DESCRIPTION                                                Date             Cost       VALUE

                                                                                P          P




 TOTAL                                                                          P          P
May be reproduced if necessary                                                                  Revised 03/31/04




                                          _________________________________________
                                           Signature over Printed Name of AMO

                                          _________________________________________
                                                        Company Name

                                          _________________________________________
                                             PCAB License No. (If applicable)

                                          ________________________________________
                                                         Date Signed

CFY _________________
Type of Application: (Pls. check)
       New
       Upgrading
       Renewal
       Others, pls. Specify
            __________________________
                                                                                 PCAB Form No. 106c




            LIST OF NOMINATED SUSTAINING TECHNICAL EMPLOYEES OF THE COMPANY

                                                PRC REGISTRATION
                                                                             Date       Position
          NAME                                                             Employed   in the Firm
                                           Number     Date    Profession




May be reproduced if necessary                                                         Revised 03/31/04




                                 _______________________________________
                                    Signature over Printed Name of AMO


                                 _______________________________________
                                          Company Name


                                 _______________________________________
                                     PCAB License No. (If applicable)


                                    ______________________________________
                                               Date Signed


CFY __________________
Type of Application: (Pls. check)

          New
          Upgrading
          Renewal
          Others, pls. Specify
           __________________________
                                                                                                                PCAB Form No. 107
                                         SCHEDULE OF RECEIVABLES

To be accomplished if the applicant's receivable accounts (accounts/contracts & other receivable) exceed 50% of the total
networth/equity as of the latest audited balance sheet submitted in support of its application.
                 TYPES                         AMOUNT            AGE          NAME/ADDRESS OF DEBTOR/CLIENTS




Notes: * All receivable accounts must be substantiated by confirmation of debtors/clients
         Please use additional sheets if necessary




                                            SCHEDULE OF INVENTORIES

To be accomplished if the applicant's inventory accounts exceed 5% of the total networth/equity as of the latest audited balance sheet
submitted in support of its application.
                                                                    Intended Use or
              Types                     Amount       Age/Date                               Physical         Place of Storage
                                                                      Purpose for
                                                     Acquired           Storing             Condition




Please use additional sheets if necessary
PCAB Form No. 108



                                                                                                   Passport size
                                                                                                  Picture of STE
Republic of the Philippines )
Province of _____________ )
Municipality of ___________) S.S.

                                                        STE AFFIDAVIT
 I,____________________________________________________________________, Filipino, of legal age,
              LAST NAME                    FIRST NAME               COMPLETE MIDDLE NAME
born on                                    single/married to __________________________________________and
            M M / D D/ Y Y Y Y
residing at ____________________________________________________________________ having duly sworn in
accordance with law depose and say:
1. That I am a duly licensed __________________________ and holder of PRC registration no. ___________
                                             (PROFESSION)
     valid up to _______________ (copy of my PRC is attached at the back hereof);
2. That I hold a Bachelor's Degree in _________________________________________________________ at
   ______________________________________________________ given on _____________________;
                       (NAME OF SCHOOL)
3. That my Tax Identification Number (TIN) and Social Security No. are        -         -
   and           -                       -       respectively;
4.    That I am not presently employed in any government office or government owned/controlled corporation, nor a full time
      instructor, nor working abroad;
5. That I am employed by _________________________________________________________________
                                                                    (NAME OF FIRM)
     on regular and full-time basis with the position of _________________________________and presently being
     nominated as Sustaining Technical Employee for CFY _____________;
6. That I am not a holder of a contractor's license;
7. That I am not involved in any construction malperformance suggestive of negligence, incompetence or malpractice or
   any act of omission liable for disciplinary action by myself or in collaboration with any other person;

8. That I have not been convicted by a court of competent jurisdiction of any offense involving moral turpitude;

9.    That I am fully aware that my failure to notify the PCAB of my disassociation with my present employer shall cause
      my disqualification to be sustaining technical employee or authorized managing officer or a license applicant with
      PCAB;
10. That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever
     sources PCAB may consider appropriate;
11. That I am executing this affidavit to attest to the truth of the foregoing.
FURTHER AFFIANT SAYETH NAUGHT.
                                                                                        _________________________________
                                                                                                  Affiant
SUBSCRIBED and sworn to before me this _____ day of ___________________, 200___ affiant exhibited his/her
Community Tax Certificate No. _____________ issued at ___________________ on ______________.

Doc. No. __________;
Page No. __________;
Book No. __________;                                                              Notary Public
Series of 200 _______.                                                     Until December 200 ___


CFY ___________________
Type of Application: (Pls. check)
          New
          Upgrading
          Renewal
          Others, pls. specify
           _____________________
                               Revised 03/31/04
                                     INSTRUCTIONS ON FILLING UP PCAB FORM NO. 108


           QUALIFICATION REQUIREMENTS OF SUSTAINING TECHNICAL EMPLOYEE
1. A technology professional, such as engineer or architect, duly licensed by the Professional Regulation Commission.

2. Holder of a Professional I.D. valid for current year.

3. Possesses at least three (3) years of experience in implementation of construction to which he is to be nominated

4. A full-time employee of the nominating contractor, not associated professionally or by employment with any other
   party, particularly a party engaged in construction or construction-related activities

5. Have none of the following disqualifications:

     a) Involvement, in any capacity, in any construction malperformance of grave consequence, suggestive of his
        negligence, incompetence and/or malpractice;

     b) Involvement, by himself or in collaboration with any other person or firm, in any act or omission liable for
        disciplinary action of which he is or the other person or firm was found guilty by the Board;

     c) Conviction by a court of competent jurisdiction of any offense involving moral turpitude; and

     d) If formerly a Sustaining Technical Employee or an Authorized Managing Officer of any construction firm but
        disassociated therefrom, failure to notify the Board of his disassociation in accordance with paragraph 5 and 6
        of the Affidavit of Undertaking.
6. Not a holder of a Contractor’s License.

    If you meet the above requirements, kindly accomplish this affidavit. Erasure must be properly initialled.

    All statements are subject to verification and any false statement or willful misrepresentation of a material fact in
obtaining a license shall be grounds for disapproval of this application.




                             PASTE                                                 PASTE

                        PROF. I.D. CARD                                       PROF. I.D. CARD

                           VALID FOR                                             VALID FOR

                        CURRENT YEAR                                           CURRENT YEAR

                                                                                    (Back)
                              (Front)                                            (xerox copy)
                           (xerox copy)




       This is to certify that I have verified with PRC the abovestated professional eligibility/registration of the
       Sustaining Technical Employee. Affiant herein and found the same to be true and correct.




                                       __________________________________________
                                          Signature over Printed Name of the AMO
                                               Date: _______________________
                                                                                                            PCAB Form No. 109
Republic of the Philippines    )
Province of _____________      )
Municipality of ___________) S.S.

                            AFFIDAVIT OF STE CONSTRUCTION EXPERIENCE
           I, _________________________________, single/married, Filipino, of legal age, with postal address at
 ________________________________________________, having been duly sworn in accordance with law depose and
 say that the projects enumerated below constitute my full & complete construction experience.

                 NAME and                                     Work            Nature/Scope of              PROJECT
      COMPLETE ADDRESS of EMPLOYER/                       Classification      Work Assignment             DURATION
  NAME & LOCATION of PROJECTS UNDERTAKEN                  (GE, GB, SP)          (Proj. Engr.)             (mm/dd/yy)
                                                                                                From                   To




That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever sources PCAB
may consider appropriate;
That I am executing this affidavit to attest to the truth of the foregoing.
 FURTHER AFFIANT SAYETH NAUGHT.
                                                                                        _________________________________
                                                                                                Affiant
 SUBSCRIBED and sworn to before me this _____ day of _________________, 200__ affiant exhibited his/her Community
 Tax Certificate No. ______________ issued at ____________________ on ____________________.

 Doc. No. __________;
 Page No. __________;
 Book No. __________;                                                                   Notary Public
 Series of 200 _______.                                                              Until December 200 ___
 CFY ___________________                                            Company Name ____________________________
 Type of Application: (Pls. check)                                  PCAB License No. __________________________
          New
          Upgrading
          Renewal
          Others, pls. specify
            ___________________________
                                     Revised 03/31/04
                                                                                           PCAB Form No. 110



         SUSTAINING TECHNICAL EMPLOYEE (STE) PERSONAL APPEARANCE FORM
                           (To be accomplished fully by the STE)

Name: ______________________________________________ Sex: __________________
Address: ____________________________________________________________________
Profession: __________________________________        PRC Reg. :_____________
Nominating Firm: ____________________________________________________________
Contractor's License No.: ______________________

I hereby confirm the following:
1. The veracity of the information reflected on the STE Affidavit and Affidavit of Construction Experience
   (PCAB Form Nos. 107 & 108, copies attached) that I executed in favor of the above firm;
2. That I am fully aware that my failure to notify the PCAB of my disassociation from the above-stated
   nominating firm and any misrepresentation in the attached forms shall cause my disqualification as
   sustaining technical employee, or authorized managing officer, or a licensee applicant with PCAB per
   Board Resolution No. 401, Series of 2001.

3. That I have been previously connected with the following companies:

                                                                Date of         Date of
                      Previous Employers                      Employment      Resignation          Position




4. Other Remarks:
    ___________________________________________________________________________
    ___________________________________________________________________________


                                                            ______________________________
                                                                         STE's Signature

                                                          Date Signed: _______________________


                                                             Identification Documents Presented:
                                                              1. PRC ID No. ____________________
                                                                 valid until ______________________

                                                              2. ______________________________

Personal Appearance and Presentation
of Two (2) Identification Documents
attested by PCAB designated staff or
DTI Regional/Provincial Staff


_______________________________
Signature over Printed Name/Position

DTI Office Address: ______________________________________________
Date: ____________________________
                                                                                 PCAB Form 111-A
                                                                                 (For sole proprietorship)


Republic of the Philippines) s.s.
______________________)

                                                     AFFIDAVIT


   I, _______________________________, of legal age, Filipino, married/single with postal address at
____________________________________, after having been sworn to in accordance with law, hereby depose
and say:

        1. That     I    am      the     Proprietor/Authorized Managing                     Officer      (AMO)        of
           __________________________________________________________;
                                   (Name of Firm)

        2. That I appoint ____________________________, whose picture and signature appear below, to transact
           business with PCAB; i.e, present for pre-screening my application for contractor’s license or any application
           related thereto, file/follow-up, submit documents, receive notices/license in connection with the said
           application and the like.




                          Passport size                         ______________________________
                           Picture of                              (Signature over Printed Name)
                         Representative
                                                                ______________________________

                           __________                           ______________________________
                                                                       HOME /MAILING ADDRESS




        3. That I am aware that I am responsible/liable for any or all acts/representation made by my representative in
           connection with the functions stated herein.

        4. That I undertake to notify PCAB in the event that this appointment is modified, amended or revoked.


                                                           _______________________________________
                                                                                AFFIANT

SUBSCRIBED and sworn to before me this ______ day of ____________, 20___, affiant exhibited his/her
Community Tax Certificate No. _______________ issued at ___________ on ___________________.

Doc No. __________                                                Notary Public
Page No. _________                                                Until December 200 ___
Book No. _________
Series of _________


(Note: Please submit original and one duplicate to PCAB. Keep another copy for presentation everytime you transact
with PCAB)
                                                                                                 PCAB Form 111-B
                                               (For corporation.,partnership,cooperative joint venture or consortium)

Republic of the Philippines) s.s.
______________________)

                                                    AFFIDAVIT



   I, _______________________________, of legal age, Filipino, married/single with postal address at
____________________________________, after having been sworn to in accordance with law, hereby depose
and say:

        1. That    I    am    the       Authorized Managing                Officer     (AMO)       of     __________
           ________________________________________;
                         (Name of firm)

        2. That the abovestated firm had duly appointed ____________________________, whose picture and
           signature appear below, to transact business with PCAB; i.e, present for pre-screening its application for
           contractor’s license or any application related thereto, file/follow-up, submit documents, receive
           notices/license in connection with the said application and the like.


                                                                ______________________________
                          Passport size                            (Signature over Printed Name)
                           Picture of
                         Representative
                                                                ______________________________

                                                                ______________________________
                                                                     HOME /MAILING ADDRESS




        3. That we are aware that we are responsible/liable for any or all acts/representation made by the above
           representative in connection with the functions stated herein.

        4. That the firm undertakes to notify PCAB in the event that this appointment is modified, amended or revoked.
           ________________________
                                                                           AFFIANT

SUBSCRIBED and sworn to before me this ______ day of ______________, 20__ affiant exhibited his/her
Community Tax Certificate No. _______________ issued at ___________ on ___________________.

Doc No. __________                                               Notary Public
Page No. _________                                               Until December 200 ___
Book No. _________
Series of _________

(Note: Please submit original and one duplicate to PCAB. Keep another copy for presentation everytime you
transact with PCAB)

								
To top