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PCAB F PCAB-PAD-CMO-F01 CHANGE OF AUTHORIZED MANAGING O Revision 00 R Eff. Date 11/8/2010 OFFICER APPLICATION M 1 of 5 Page REQUIRED ITEMS The following pertinent documents and information shall be submitted in support of Change AMO of PCAB license application.(Applicant may Initially fill out the check boxes subject for final validation by PCAB/DTI-ROG pre-screener) A. LEGAL In behalf of ____________________________________________________________________________ (Name of Firm) holder of Contractor’s License No. ________, originally issued on ______________ and last renewed during the CFY 20__ - 20__ , I hereby request for change of Authorized Managing Officer (AMO) as follows: Name Nationality From : ____________________________________ ________________________________ To : ____________________________________ ________________________________ 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. _______________________________ Authorized Managing Officer (Signature over Printed Name) Republic of the Philippines ) Province of ______________) City/Municipality of ___________) 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. Series of 20 __. NOTARY PUBLIC (Until December 31, _______) PCAB F PCAB-PAD-CMO-F01 O Revision 00 R Eff. Date 11/8/2010 M Page 2 of 5 For Corporations or Associations with foreign shareholders, the following documents shall be submitted: 1. Corporate Secretary’s Certification as follows: a. List of stockholders showing their nationalities and shareholdings; and b. List of Board of Directors showing their names and nationality. 2. Copy of latest General Information Sheet duly filed with SEC showing the names of stockholders and directors, nationality and shareholdings. The percentage control of the number of seats occupied by foreigners in the Board of Directors shall not exceed 40%. Complied CHECLIST OF REQUIREMENTS: Yes No N/A 1. AMO Nomination / Original Corp. Secretary's certificate as to the [ ] [ ] [ ] nomination of the AMO(Page 4 of 5); 2. AMO Affidavit (Page 3 of 5) with a passport size picture of AMO; [ ] [ ] [ ] 3. Original NBI Clearance of Filipino Authorized Managing Officer (AMO) and [ ] [ ] [ ] non-Filipino AMO who has resided in the Philippines for six (6) months or longer; 4. Certified true copy of NBI Clearance Equivalent for non-Filipino AMO/RAR [ ] [ ] [ ] duly authenticated by the Phil. Embassy in the home country of the AMO/RAR; 5. Original copy/certified true copy by the BID of the Alien Certificate of Registration (ACR) [ ] [ ] [ ] & valid working visa. 6. Certified copy latest General Information Sheet submitted to SEC. (for corporations [ ] [ ] [ ] only) Note: Photo/xerox copies of documents may be submitted provided that original documents are Presented for comparison to PCAB. D. OTHERS D.1. Original Signature of AMO on each and every page of the application forms including Supporting documents. [ ] [ ] [ ] D.2 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 applicants; [ ] [ ] [ ] D.3 New AMOs’/Applicants shall be required to take the AMO Examinations except category [ ] [ ] [ ] TRADE applicants. D.4 Self-stamped envelopes (One self stamped mailing envelope is required for each [ ] [ ] [ ] supporting document submitted.) D.5 Applicants interested to participate in government projects should accomplish Application for Registration and Classification of Government Projects(PCAB-PAD-ARC- [ ] [ ] [ ] F01) and file the same together with the PCAB Application Form. D.6 Accomplished Affidavit for Firm’s Authorized Representatives [ ] [ ] [ ] FOR PCAB/ DTI-ROG USE ONLY No. of Pre- Prescreening Results Filed Pre-screener / Date screening 1st [ ] Comply lacking items as listed in the Remarks [ ] Accepted [ ] PCAB Makati [ ] DTI-ROG 2nd [ ] Comply lacking items as listed in the Remarks [ ] Accepted [ ] PCAB Makati [ ] DTI-ROG 3rd [ ] Comply lacking items as listed in the Remarks [ ] Accepted [ ] PCAB Makati [ ] DTI-ROG REMARKS: LETTER / ITEM NO. COMMENTS: PCAB F PCAB-PAD-CMO-F01 O Revision 00 R Eff. Date 11/8/2010 M Page 3 of 5 AMO AFFIDAVIT Recent Photo Republic of the Philippines ) Province of ______________ ) Passport Size City/Municipality of ___________ ) S.S. SURNAME FIRSTNAME MIDDLE NAME I, DD MM YYYY Single / Married SURNAME FIRSTNAME MIDDLE NAME Born on to ST. # & NAME BARANGAY DISTRICT CITY/MUNICIPAL PROVINCE ZIPCODE and residing at: Having duly sworn in accordance with law depose and say: 1. That I am the Authorized Managing Officer of : ________________________________________________________________________________ (Name of firm) 2. That I possess the following educational attainments (attach additional sheet if necessary) NAME OF SCHOOL ADDRESS COURSE INCLUSIVE DATES 3. That I possess at least two (2) years experience in the construction industry as follows (Ref. Sec. 20 of IRR of R.A. 4566) (attach additional sheet if necessary) DESIGNATION / COMPANY / NATURE DATES OF ADDRESS JOB DESCRIPTION POSITION OF BUSINESS EMPLOYMENT 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 (Ref. Sec. 20 of IRR of R.A. 4566): 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 (Section 4.2 of IRR of R.A. 4566) 6. That I have not been convicted by a court of competent jurisdiction of any offense involving moral turpitude (Rule (Section 4.2 of IRR of R.A. 4566) 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 . 8. That I authorize the PCAB to verify and investigate any or all information in this instrument from whatever sources PCAB may consider appropriate 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 _________________, 20___ affiant exhibited his/her Community Tax Certificate No. __________ issued at _____________________ on ________________. Doc. No. Page No. Book No. NOTARY PUBLIC Series of 20__ Until December 20__ PCAB F PCAB-PAD-CMO-F01 O Revision 00 R Eff. Date 11/8/2010 M Page 4 of 5 SECRETARY’S CERTIFICATION (for Corporation/Cooperatives only) Republic of the Philippines ) Province of _____________ ) City/Municipality of ________) S.S SURNAME FIRSTNAME MIDDLE NAME I, ST. # & NAME BARANGAY DISTRICT CITY/MUNICIPAL PROVINCE ZIPCODE and residing at: do hereby certify, in my capacity as the duly elected and incumbent Corporate Secretary of ______________________________________________________________________________ (Name of firm) DD MM YYYY Held CITY / MUNICIPALITY OF MEETING That during its regular meeting held on at Wherein a quorum was present , the following resolution was unanimously approved, to wit: AMO NOMINATION "R E S O L V E as it is hereby resolved that _______________________________________________________________________, (FIRSTNAME MIDDLENAME SURNAME) a senior executive who has been granted the power to render general management and administrative decision, be appointed as the firm's Authorized Managing Officer 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. _________________________________ Corporate Secretary (Signature Over Printed Name) SUBSCRIBED and sworn to before me this ________ day of _______ 20___ affiant exhibited to me his/her Community Tax Certificate. No. ____________ issued on _____________ at ________________________. Doc. No. Page No. Book No. Series of 20 __. NOTARY PUBLIC Until December 20 ____ PCAB F PCAB-PAD-CMO-F01 O Revision 00 R Eff. Date 11/8/2010 AFFIDAVIT OF REPRESENTATIVE M Page 5 of 5 Republic of the Philippines ) Province of _____________ ) City/Municipality of ________) S.S 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. Representative Signature over printed Passport Size Photo Most Recent Taken within the last six Address: _______________________ months prior to application of PCAB license _______________________________ 3. That I am aware that I am responsible/liable for any or all acts/representation made by my Type of Application: (Pls. check) representative in connection with the functions stated herein. New Upgrading 4. RenewalThat I undertake to notify PCAB in the event that this appointment is modified, amended or revoked. Others, pls. specify _______________________ ______________________________________ AFFIANT (Authorized Managing Officer of Firm) SUBSCRIBED and sworn to before me this ______ day of ____________, 20___, affiant exhibited his/her Community Tax Certificate No. _______________ issued at ___________ on ___________________. Type of Application: (Pls. check) New Upgrading NOTARY PUBLIC Type of Application: (Pls. check) Renewal Type of Application: (Pls. check) Until December 20 ____ New New Upgrading (Pls. check) TypeOthers, pls. specify of Application: New _______________________ Upgrading Renewal Upgrading Others, pls. specify Renewal No. Doc. _______________________ Renewal Others, specify Page No. pls. specify Others, pls. _______________________ _______________________ Book No. Series of 20 __.
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