PEZA Form. ERD.-4-F.

003

Republic of the Philippines

PHILIPPINE ECONOMIC ZONE AUTHORITY
PEZA Building, Roxas Boulevard corner San Luis Street, Pasay City
Telephone: 551-3451 Local 231; Fax: 891-6381 website: www.peza.gov.ph
APPLICATION FOR REGISTRATION/ACCREDITATION
AS AN ECOZONE SERVICE ENTERPRISE
(For Customs Broker, Freight Forwarder, Trucker/Hauler and Security Agency)
Customs Brokerage ( )
Application No. ___________
Freight Forwarding ( )
Date Filed
___________
Trucking / Hauling
( )
Official Receipt No. _________
Security Agency
( )
Amount Paid
___________
Name of Firm: _______________________________________________________________
Address:
_______________________________________________________________
_______________________________________________________________
Telephone No. ______________ Fax No. _____________ E-mail_______________________
Applicants Representative to PEZA (Contact Person):
Name:
_______________________________________________________________
Address :
_______________________________________________________________
Telephone No. ______________Fax No. ______________E-mail _______________________
Applicants Existing Business Registration with:
Office
Date
Registration No.
Securities and Exchange Commission (SEC)
________________ ________________
Department of Trade and Industry (DTI)
________________
________________
Bureau of Customs (BOC)
________________
________________
Social Security System(SSS)
________________
________________
Bureau of Internal Revenue (BIR)
________________
________________
Dept. of Labor & Employment (DOLE) NLRC
________________
________________
Cooperative Development Authority (CDA)
________________ ________________
Others, please specify_________________
________________
________________
Nature of Business Entity:
Single Proprietorship
( )
__________________________________
Partnership
( )
__________________________________
Corporation
( )
__________________________________
Cooperative
( )
__________________________________
Others (Please Specify) ( )
__________________________________
Issued Licenses/Permits (pls. check)
______ Mayors Business Permit No. _______________________valid until _____________
______ Customs Brokerage Licenses. Person and Firms, valid until_____________________
______ Copy of Franchise from LTO: Case Decision from LTFRB valid until ______________
______ LTO Registration Certificate/O.R. of vehicles approved under LTFRB Case Decision
______ Annual Permit to Operate /Clearance from Philippine Port Authority (PPA)
______ Certificate of Accreditation from the Philippine Shippers Bureau (for Sea Freight)
______ Authority to Operate from the Civil Aeronautic Board (for Air Freight)
______ PNP Clearances: (i) PNP Regular Permit to Operate or Temporary License to
Operate valid until ________________________ and (ii) updated firearms Licenses
______ Latest Disposition Report validated by PNP-SAGSD dated ____________________
______ Bond with PNP (copy only) valid until _____________________________________

Project Summary:
1. Brief Description of the Project (Describe Operations, services to be provided in the Zone,
arrangement, etc.)

2. Brief Business History of Applicant

(Please attach separate sheet, if necessary)

3. Organization Chart: (please attach separate sheet)

Write up on the Organization:

4. Financial Institutions from which the Applicant Intends to Obtain Financing:

Bank References:

5. Capital Structure- For Corporations Only (Value in Peso)

Common Stock
_____________

Authorized No.
_____________
No.

Amount (PhP)

Par

_____________

Subscribed
Value
% to Total

_____________
No.

Paid-Up
Value
% to Total

1. Filipino
a.
b.
c.
d.
e.
2. Non-Filipino
Total
6. Capital of Partnership or Single Proprietor
Nationality
(Indicate if
Name
Naturalized)
Address

Capital

7. Business Activities Other Than Those Covered by Application

% to
Firms
Total

Tax
A/C
No.

Name of Company
______________________
______________________
______________________
______________________

Location/Address
________________________
________________________
________________________
________________________

Product/Service
__________________
__________________
__________________
__________________

8. Applicants Incorporators (For Corporation Only)

No. of
Shares

Name

Tax
A/C No.

No. of
Shares

Name

Tax
A/C

No.

9. Principal Officers
Nationality
(Indicate if
Name
Position
Naturalized)
_______________ ______________ _____________
___________
_______________ ______________ _____________
___________
_______________ ______________ _____________
___________
_______________ ______________ _____________
___________
_______________ ______________ _____________

Address
_______________

Tax
A/C No.

_______________
_______________
_______________
_______________

__________
_______________ ______________ _____________
___________

_______________

(Please attach list of personnel authorized to transact with PEZA)

10. Type of Service and Service Rates:
(Please attach separate sheet if necessary)
Service

Rate

11. Attach other documents as listed in checklist or standard application requirements

THE FOLLOWING DOCUMENTS ARE TO BE ATTACHED AS AN INTEGRAL

PART OF THIS APPLICATION

1.
2.
3.
4.
5.

DTI/SEC Certificate of Registration, Articles of Incorporation and By-Laws (if existing)

Anti-Graft Certificate, Republic Act No. 3019 (see attached)
Certificate of Official Filing of Application
Bio-data of Principal Officers
Audited Financial Statements for the last three (3) years, (for existing company)

Done in the City/Province of_______________________________________ this _______

day of _________________________________, __________ .

____________________
Affiant
___________________
Designation
Republic of the Philippines)
)S.S.
City/Province
)
SUBSCRIBED AND SWORN to before me this ___ day of _________________,
_____
in the City/Province of __________________________, Affiant exhibited to me his
Community Tax Certificate No. ____________ issued at
_____________________________________ on _______________________ ,
____________ .

________________________
Notary Public
Until December 31,_______

Doc. No _____________
Page No._____________
Book No. ____________
Series of_____________

APPLICANTS NOTARIZED UNDERTAKING

In applying for PEZA registration/accreditation, the applicant herewith makes the following
representations and commitments:

1. The applicant is capable is operating on a sound and efficient basis and of

contributing to the objectives of the Philippine Economic Zone Authority (PEZA) and
to the development of the national economy in general. Its project is economically,
and financially sound.
2. Applicant proposes to engage in good faith in creating a market for its services.
3. Applicant shall submit periodic reports and other information that the Authority may
require on its activities in the Ecozone.
4. The applicant has read R.A. 7916, as amended, and the Rules and Regulation
adopted by the PEZA and commits itself to abide by the provisions thereof and
amendments thereto.
5. The applicant will start and operate the project covered by this application within such
reasonable times as may be fixed by the Authority.
6. If the applicant is a corporation, the Board of Directors of applicant has authorized
the filling of this application in accordance with the terms thereof.
7. That pursuant to the provision of Sec. 3 and Sec. 14 of R. A. 3019 (Anti-Graft Act),
the applicant-enterprise has not given or promised to give and will not give any gift to
any officer or employee of the Philippine Economic Zone Authority (PEZA) in
connection with the filling and processing of this application.
8. That based on the records of the applicant no PEZA Board members or department
Directors and or employee of the PEZA has an investment of any other financial
interest, direct or indirect, in the applicant enterprise.
9. That there exists no dummy relationship between the stockholders or Directors of the
applicant and any foreigner.
Done in the City/Province of _____________________________________ this ________
day of _________________________________, __________ .
_______________________
Affiant
_______________________
Designation
SUBSCRIBED AND SWORN to before me this ___ day of _______________, _____
In the City/Province of _________________________, Affiant exhibited to me his
Community
Tax
Certificate
No.__________
issued
at
_________________________________, on ___________________________, _______.
____________________________
Notary Public
Until December 31,____________
ANNEX A
ANTI-GRAFT CERTIFICATE
I, ________________________________________, of legal age, President/General

Manager of ________________________________________________ with postal address

at _______________________________________________________________________
after having been duly sworn, dispose and say:
That pursuant to the provisions of Section 3 and 14 of R.A. 3019 (Anti-Graft and
Corrupt Practices Act), the applicant enterprise, __________________________________
has not given or promised to give, and will not give, any gift in cash or in kind or any benefit
to any officers, employees of the Philippine Economic Zone Authority (PEZA) in connection
with the filing and processing of the application, nor will give such gift or benefit 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 business of the applicant; and
That this Certificate was made with the approval of applicants Board of Directors.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ______________, ___

In the City/Province of ___________________________, Affiant exhibited to me Community
Tax Certificate No. _________________ issued at ______________________________ on
_________________________, __________.
______________________
Notary Public
Until December 31, ______
Doc. No. _____________
Page No. _____________
Book No. _____________
Series of______________

ANNEX B

CERTIFICATE OF OFFICIAL FILING OF APPLICATION

I, ______________________________________________, of legal age, Filipino, with

address at _______________________________________________________________
depose and state:
That I am the President/General Manager of ________________________________
(the Company), a domestic corporation duly organized and existing under the laws of the
Republic of the Philippines, with principal office at _________________________________,
and I officially represent the company for purposes of filing of its application with PEZA for
authorization to provide _______________________________________________ services
to all PEZA-administered economic zones.
That the contents of the herein application filed with PEZA for registration/accreditation
as an Ecozone Services Enterprise are true and correct to the best of my knowledge.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ____________, ______

in the City/Province of _____________________________, Affiant exhibited to me
Community Tax Certificate No. ____________ issued at __________________________ on
________________________, __________.

______________________
Notary Public
Until December 31, ______

Doc. No. _____________

Page No. _____________
Book No. _____________
Series of______________