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EDD.1.F.012
Revised.8.12.09
APPLICATION FOR REGISTRATION OF
ECONOMIC ZONE UTILITIES ENTERPRISE
_____________________________
Date
Hon. LILIA B. DE LIMA
Director General
Philippine Economic Zone Authority
Madam:
In accordance with Chapter II, Section 12 (c) of Republic Act No. 7916, otherwise known
as the Special Economic Zone Act of 1995, as amended by Republic Act No. 8748, and its
Implementing Rules and Regulations, I am applying for the registration of
_________________________________________________________________________________
(Name of Company)
as Economic Zone Utilities Enterprise for the establishment, operation and maintenance of
_________________________________________________________________________________
(Nature of Project)
to be located at
(Name and Location of Ecozone)
The undersigned attest that the documents/information submitted are true and are correct and that I
assume full responsibility for any misrepresentation and/or violation thereof.
Attached hereto are:
1. Duly accomplished and notarized PEZA Application Form and anti-graft certificate (R.A. 3019);
2. Board Resolution authorizing the filing of the application with PEZA and designation of representative(s) authorized
to transact registration with PEZA;
3. Securities and Exchange Commission (SEC) Registration including Articles of Incorporation and By-Laws;
4. Audited financial statements for the last three (3) years, if applicable;
5. Project Description (Development Plan and Timetable);
6. Drawing/Layout of typical support structure arrangement;
7. Complete Operational Plan including capacity plan (current and future demand);
8. Environmental Compliance Certificate issued by the Department of Environment and Natural
Resources/Environmental Management Bureau (DENR/EMB), if applicable;
9. Favorable endorsement from the economic zone developer/operator
A. Water Utilities
1. Certification from the National Water Resources Board; and
2. Favorable endorsement from the local water district of the host municipality
B. Power Utilities
1. Favorable endorsement from the Department of Energy
Very truly yours,
President/CEO
EDD.1.F.012
Revised.8.12.09
Republic of the Philippines
PHILIPPINE ECONOMIC ZONE AUTHORITY
Roxas Blvd. cor. San Luis Street, Pasay City, Metro Manila, Philippines
Telephone No. (632) 551-3440 Telefax No. (632) 551-9518 E-mail Add. edd@peza.gov.ph
APPLICATION FOR REGISTRATION OF
ECONOMIC ZONE UTILITIES ENTERPRISE
Date Filed
O.R. No. / Date
A. APPLICANT
Company Name
TIN No.
Address
Telephone No.
Fax No.
Email Address
Website
B. AUTHORIZED REPRESENTATIVE
Name
Address
Telephone No.
Fax No.
Email Address
C. TYPE OF APPLICATION (Please Check)
New Ecozone Utilities Enterprise
Expansion/Additional Project
Site of Operation
Location _____________________________________________________________
(Lot No. Block No. Phase No. )
Name of Ecozone ________________________________________________________
D. PROJECT BRIEF
The Proponent
1. Name of Company
2. Company Address
EDD.1.F.012
Revised.8.12.09
3. SEC Registration
Cert. of Registration No.
Date
Amendment (if any)
Nature
Date
4. Nature of Business
5. Incorporators
NAME NATIONALITY
Use separate sheet/s if necessary
6. Current Stockholders
AMOUNT OF
NO. OF AMOUNT OF PAID-
NAME NATIONALITY SUBSCRIBES
SHARES UP SHARES
SHARES
Use separate sheet/s if necessary
7. Principal Officers
NAME POSITION
Use separate sheet/s if necessary
8. Capital Structure a. Authorized
b. Subscribed
c. Paid-Up
9. Affiliate Company
NAME OF COMPANY CAPITALIZATION
PhP
Use separate sheet/s if necessary
EDD.1.F.012
Revised.8.12.09
10. Other Project Involvements
YEAR
NAME OF PROJECT DESCRIPTION
ESTABLISHED
Use separate sheet/s if necessary
The Land
1. Location
2. Land Area
3. Ownership/Right Over Land q Full Ownership q Lease Contract
q MOA q Joint Venture Agreement
q Others
The Project
1 Status of Development New development Under development
Existing/Fully developed
If new development
i) date of commencement
ii) expected date of completion
If under development
i) percentage completion
ii) date started
iii) expected date of completion
If existing/fully developed
i) date established
ii) status of occupancy
iii) line of business of occupants
2. Labor Requirements
Projected No. of Workers/Employees
Year
Direct Indirect
1
2
3
Average
EDD.1.F.012
Revised.8.12.09
3.. Detailed Descriptions of Project (Technical Specifications)
Use separate sheet/s if necessary
4. Description of Operation and Maintenance (i.e. capacity, schematic diargram of system's flow)
Use separate sheet/s if necessary
5. List of Machinery and Equipment to be used (please include source and costs)
Machinery and Equipment Source Unit Cost per Unit Amount
Use separate sheets if necessary
6. Five (5)-year Projected Power/Water Demand
Year Projected Capacity Projected Demand Remarks
1
2
3
4
5
6. Schedule of Rates
7. Proposed/Existing On-Site Utilities, Facilities and Amenities
a. Telecommunication System
i) Telephone provider
ii) No. of lines
b. Water Supply System
i) Source
ii) Distribution system
c. Sewerage and Drainage System
d. Sewage Collection, Treatment and Disposal
i) Wastewater collection
ii) Wastewater treatment
EDD.1.F.012
Revised.8.12.09
iii) Wastewater disposal
iv) Wastewater recycling
e. Solid Waste Disposal System
f. Fire Fighting System
g. Other Utilities, Facilities and Amenities
8. Proposed Community Development Project
9. Proposed Improvements (for existing project, if any)
10. Estimated Project Cost Breakdown
COMPONENT AMOUNT
Land Acquisition Cost PhP
Land Development Cost
Horizontal development cost
Vertical development cost
Improvement Cost
Other costs
TOTAL PhP
11. Sources of Funds
SOURCE PERCENT SHARE
Use separate sheet/s if necessary
12. Marketing Program/Promotional Strategies
13. Environmental Management Program
a. Liquid Waste Management Program
b. Solid Waste Management Plan
c. Toxic and Hazardous Waste Management Plan
d. Prevention and Abatement of Pollution (air, noise, water)
EDD.1.F.012
Revised.8.12.09
Done in the City/Province of ____________________________________________________________
this day of 20
___________________________
Affiant
____________________________
Designation
Republic of the Philippines )
) S.S.
Municipality/City/Province of
Subscribed and sworn to before me this day of 20
in the Municipality/City/Province of
Affiant exhibit to me his Residence Tax Certificate No
issued at on 20
_________________________________
Notary Public
Until December 31, 20______
Doc. No.
Page No.
Book No.
Series of
EDD.1.F.012
Revised.8.12.09
14. Projected Income Statement
Y1 Y2 Y3 Y4 Y5
Revenues
Less: Cost of Services Sold
Direct Materials
Direct Labor
Mfg. Overhead
Gross Profit
Less: Operating Expenses
Selling, General and
Research and
Operating Income
Less: Other Expenses
Interest Expense
Income Before Income Tax
Less: Provision for Income Tax
Net Income
15. Projected Balance Sheet
Y1 Y2 Y3 Y4 Y5
ASSETS
Current Assets:
Cash
Account Receivable
Inventories
Other Account Assets
Total Current Assets
Fixed Assets:
Gross Fixed Assets
Less: Accumulated Dep'n
Net Fixed Assets
TOTAL ASSETS
LIABILITIES and
STOCKHOLDERS' EQUITY
Current Liabilities
Accounts Payable
Accrued Expenses
Advances from Affiliates
Other current liabilities
Total Current Liabilities
Long-Term Liabilities
Other non current Liabilities
TOTAL LIABILITIES
STOCKHOLDERS' EQUITY
Paid-up Capital
Additional Paid-in Capital
Deposits on Subscription
Retained Earnings
TOTAL LIABILITIES and
STOCKHOLDERS' EQUITY
EDD.1.F.012
Revised.8.12.09
APPLICANT'S UNDERTAKINGS
In applying for PEZA registration, the Applicant herewith makes the following representations and commitments:
1 . That the applicant is capable of operating, on a sound and efficient basis, and of contributing to the
objectives of the Philippine Economic Zone Authority in particular and to the development of the national
economy in general;
2 . That the project is economically, technically and financially sound;
3 . That the applicant proposes to engage, in good faith, in the creation of a market for its project/product;
4 . That the applicant has installed/undertakes to install an accounting system adequate to identify the
investments, revenues, costs and profits or losses of the project covered by this application separately from
the aggregate investments, revenues, costs and profits or losses of the other business activities of the
applicant not registered under Republic Act No. 7916, as amended by Republic Act 8748 or has
established/undertakes to establish a separate entity for the project/activities covered by this application if
so required by the Authority. (Applicable only if applicant is engaged or proposes to engage in undertaking
or activities in addition to the project covered by this application);
5 . That the applicant shall submit periodic reports and other information, pertaining to its activities in the
Ecozone that the Authority may require;
6 . That the applicant has read Republic Act No. 7916, as amended, and the Rules and Regulations adopted by
the PEZA and commits itself to abide by the provisions thereof as well as amendments thereto;
7 . The applicant will start and operate the project covered by this application within such reasonable time as
may be fixed by the Authority;
8 . That the applicant's Board of Directors has authorized the filing of this application in accordance with the
terms thereof if the applicant is a corporation;
9 . That pursuant to Section 2(p), Rule I of the PEZA Rules, the applicant's income derived within the ecozone
shall be subject to taxes under the National Internal revenue Code pursuant to Section 25 of the Act;
10 . That no Board member or officer of the Philippine Economic Zone Authority has an investment or any other
financial interest, direct or indirect, in the applicant's enterprise; and
11 . That there exists no dummy relationship between any of the stockholders and/or principal officers of the
applicant and any foreign individuals/business entity.
Done in the City/Province of
this day of , 20 .
Affiant
Designation
Republic of the Philippines )
S.S.
City / Province of )
Subscribed and sworn to before me this_________ day of ________________ , 20___ in the City/
Province of ______________________. Affiant exhibited to me his Resident Tax Certificate No. _____________
issued at ___________________________ on _______________, 20___
Notary Public
Until December 31, 20_____
Doc. No.
Page No.
Book No.
Series of 20
EDD.1.F.012
Revised.8.12.09
ANTI-GRAFT CERTIFICATE
I, ___________________________________________, of legal age, President/General
Manager of __________________________________________________ with postal address at
_________________________________________________________ after having been duly
sworn, depose and say:
That pursuant to the provisions of Section 3 and 14 of Republic Act 3019 (Anti-Graft
Act),
the applicant enterprise, _________________________________________________ has not
given or promised to give, and will not give, any gift to any officer employee of the PEZA in
connection with the filing and processing of this application, nor it will give such gift to any of said
officers or employees after approval of its application.
That based on the records of the applicant, no Board Member or Officer of the Philippine
Economic Zone Authority has an investment or other financial interest, direct or indirect, in the
applicant; and
That this certificate was made with the approval of applicant's Board of Directors.
Affiant
Subscribed and sworn to before me this__________ day of _____________, 20 _____ in
the City/Province of ________________. Affiant exhibited to me his Residence Tax Certificate
No. _____________________ issued at _______________________ on
_________________________.
Notary Public
Until December 31, 20_____
Doc. No.
Page No.
Book No.
Series of 20
