SEC Form 12 1 SRS For Hospitals
SEC Form 12 1 SRS For Hospitals
SEC Form 12 1 SRS For Hospitals
GENERAL INSTRUCTIONS
1. Pursuant to SEC Res. No. 225, s. of 2017, hospitals may use Form 12-1 SRS for registration of
its securities that are sold or offered for sale pursuant to Section 8 and 12 of the Code. The
use of Form 12-1 SRS is without prejudice to the right of the Commission to require such
other information or documents as it may prescribe, consistent with the interest of the
general public and for the protection of investors.
2. Under Section 13.1(b) of the Securities Regulation Code (“SRC”), the Commission may reject
Registration Statement which on its face is incomplete. Notwithstanding the said provision,
Sec. 14.2 of the SRC states that an amendment filed prior to the effectivity date of the
Registration Statement (“RS”) shall recommence the forty-five (45) day period within which
the Commission shall act on a RS. Thus, should the company be amendable to extending the
45-day processing period (by executing a letter consenting to the processing time of the
application to enable the company to amend its RS) the Market and Securities Regulation
Department (“MSRD”) shall be constrained to elevate the application based on the existing
RS on file, to enable MSRD to comply with the said processing period mandated under
Section 12.6 of the SRC.
4. The registration statement shall be signed by the registrant’s chief executive officer, its chief
operating officer, its chief financial officer, its controller, its chief accounting officer, its
corporate secretary or persons performing similar functions.
5. The name of each person who signs the registration statement shall be typed or printed
beneath his/her signature. Any person who occupies more than one of the specified
position shall indicate the capacity in which he signs the registration statement. At least one
(1) copy of the documents filed shall be manually signed and the unsigned copies shall be
conformed.
7. Three (3) copies of the complete Form 12-1 SRS shall be filed including exhibits and all
other papers and documents filed as part thereof.
8. In case of withdrawal of a registration statement, fifty percent (50%) of the filing fee paid
shall be forfeited and not be allowed for future application.
9. In the event that the registration statement is rejected pursuant to Section 13 of the Code,
the filing fee paid thereon shall be forfeited.
10. Confidential Treatment of Information filed with the Commission –any request for
confidentiality will be presented to Commission En Banc prior its application for
registration or offering
11. How to use this form: Put inside the box to mark a box.
SECURITIES AND EXCHANGE COMMISSION
SEC FORM 12-1 SRS
SIMPLIFIED REGISTRATION STATEMENT FOR HOSPITALS
1. SEC Registration Number ……
Registration Statements filed pursuant to Section 12 of the Code shall be accompanied by a fee as follows:
More than P500 Million but not more than P750 P500,000 plus 0.075% of the excess over P500
Million Million
P687,500 plus 0.05% of the excess over P750
More than P750 Million but not more than P1 Billion
Million
More than P1 Billion P812,500 plus 0.025% of the excess over P1 Billion
A legal research fee of 1% of the filing fee paid for filings made pursuant to SRC Rule 8.1 shall
also be paid at the time of the filing.
Formatted: Centered
PART I - INFORMATION REQUIRED IN PROSPECTUS
1. Front of the Registration Statement and Outside Front Cover Page of Prospectus
2. Inside Front Cover and First Two or More Pages of Prospectus
3. Forward looking Statement
4. Definition of Terms
5. Executive Summary
6. Risk Factors
7. Business Information
8. Use of Proceeds
9. Description of Securities Offered
10. Plan of Distribution
11. Capitalization
12. Outstanding Securities and Principal Shareholders
13. Board of Directors
14. Management
15. Financial Information
16. Information on Independent Accountant and Other Related Matters
17. Independent Auditors and Counsels
18. Regulatory Framework
19. Corporate Governance and Board Committees
20. Other Material Factors
Give the itemized statement of all expenses of the offering other than the
discounts and commission (if applicable). If any of the securities are registered
for sale by security holders, state how much of the expenses the security holders
will pay. If the amount of any items are not known, give estimates but identify
them as such.
22. Exhibits
Exhibit
Description
No.
1. Publication of Notice re: Filing
2. Articles of Incorporation and By-laws
3. Instruments defining the rights of security holders
4. Opinion re: Legality
5. Opinion re: Tax Matters
6. Material Contracts
7. Audited Financial Statements/Audited Interim Financial Statements
8. Subsidiaries of the Issuer
9. Consent of Experts and Independent Counsel
10. Notarized Curriculum Vitae and Latest Photographs of Officers and
Members of the Board of Directors
11. Authorization re: Issuer’s Bank Account
Exhibit
Description
No.
12. Copy of Board Resolution approving the securities offering and authorizing
the filing of Registration Statement
13. Duly verified resolution of the Issuer’s Board of Directors approving the
disclosure contained in the registration statement and prospectus and
assuming liability for the information contained therein
14. Manual on Corporate Governance
15. Additional Exhibits:
Certification that all mandated government license, permit are secured and
valid
Certification on legal proceedings filed against and by the Issuer
Certification that all AFS of all subsidiaries has been filed with the Commission
(if applicable)
Certification by selling shareholder as to the accuracy of any part of the
registration statement contributed by such selling shareholders
(if applicable)
Certification from Project Engineer as to percentage of building constructed
Tax Compliance Report filed by the Issuer
Feasibility study prepared by qualified profession on the capacity of the Issuer
to provide Medical Benefits
Memorandum of Agreement with other Group of Hospitals (if applicable)
Permit to Construct Hospital issued by Bureauof Health Facilitiesand Services
(BHFS) of the Department of Health (DOH)
Credit Line Agreement
Copy of the Environmental Compliance Certificate
Copy of Development Agreement
Certified True Copy of Transfer Certificate Title
23. Furnish any other document the omission of which will render the foregoing
material facts or any other part of the Registration Statement misleading.
SIGNATURES
Pursuant to the requirements of the Securities Regulation Code, this registration statement is signed
on behalf of the registrant by the undersigned, thereunto duly authorized, in the City of
___________________on ____________________________________ .
Type of
Name I.D. Number Date/Place of Issue
Identification
NOTARY PUBLIC
Page No. ________________
Doc. No. ________________
Book No. _______________
Series of _______________
(1) Front of Registration Statement and Outside Front Cover Page of Prospectus.
On the outside front cover page of the prospectus, the information provided shall be in an easily
readable style and format and include, at a minimum, the following information:
(ii) Public offering price or the offering price range in the case of a preliminary
prospectus;
(e) The following statement in bold face 12 point type, prominently displayed:
Each investor must comply with all laws applicable to it and must obtain the necessary consent,
approvals or permission for its purchase, offer or sale under the laws and regulation in force to
which it is subject.
The company is organized under the Philippine Law. The Company is authorized to distribute
dividends out of its surplus profit, in cash, properties of the Company, shares of stock. Dividends
paid in the form of cash or property, are subject to approval of the Board of Directors of the
Company. Dividends paid in the form of additional Common Shares are subject to the approval of
the Board of Directors and stockholders who owns at least two-third (2/3) of the outstanding
capital of the company. The Board may not declare dividends as determined by the Board, taking
into consideration factors such as implementation of business plans, debt service requirements,
operating expenses, budgets, funding of new investments and acquisitions and appropriate reserves
and working capital. Refer to page ____ on Dividends and Dividend Policy of this Prospectus.
Unless otherwise, indicated, all information in this (Preliminary/Final) Prospectus is as of the date
of this (Preliminary/Final) Prospectus. Neither the delivery of this (Preliminary/Final) Prospectus
nor any sale made pursuant to this (Preliminary/Final) Prospectus shall, under any circumstances,
create implication that the information contained herein is correct as of any date subsequent to the
date hereof or that there has been no change in the affairs of the Company since such date.
No person has been authorized to give any information or to make any representation not contained
in this (Preliminary/Final) Prospectus. If given or made, any such information or representation
must not be relied upon as having been authorized by the Company. This
(Preliminary/Final)Prospectus does not constitute an offer or any securities, or any offer to sell or
solicitation of any offer to buy any of the securities of the Company in any jurisdiction, to or from
any person to whom it is unlawful to make such offer or solicitation in such jurisdiction.
Before making an investment decision, investor must rely on their own due diligence examination of
the Company and the terms of the Offer including the risks involved.
The Issuer has included in this Statement all of its representation about this offering. If anyone
gives you more or different information, you should ignore it. You should carefully review and rely
only on the information in this Statement in making an investment decision. The Investors should
be aware that risks and uncertainties might occur.
By:
Type of
Name I.D. Number Date/Place of Issue
Identification
NOTARY PUBLIC
Page No. ________________
Doc. No. ________________
Book No. _______________
Series of _______________
0TABLE OF CONTENTS
CAPITALIZATION............................................................................................................................... 1614
Capital Stock ..................................................................................................................................................................... 1614
OTHER MATERIAL FACTORS ............................................................................................................... 34 Formatted: Default Paragraph Font, Check spelling and
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Forward-looking Statements
This Prospectus contains forward-looking statements that are, by their nature, subject to significant
risks and uncertainties. These forward-looking statements include, without limitation, statements
relating to:
Such forward-looking statements are based on assumptions regarding the present and future
business strategies and the environment in which the registrant will operate in the future.
Important factors that could cause some or all of the assumptions not to occur or cause actual
results, performance or achievements to differ materially from those in the forward-looking
statements include, among other things:
Additional factors that could cause actual results, performance or achievements of registrant to
differ materially include, but are not limited to, those disclosed under “Risk Factors” and elsewhere
in this Prospectus.
These forward-looking statements speak only as of the date of this Prospectus. The registrant
expressly disclaim any obligation or undertaking to release, publicly or otherwise, any updates or
revisions to any forward-looking statement contained herein to reflect any change in the
expectations of the registrant with regard thereto or any change in events, conditions, assumptions
or circumstances on which any statement is based.
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DEFINITION OF TERMS
As used in this Prospectus, the following terms shall have the meanings ascribed to them:
“SEC” Philippine Securities and Exchange Commission Formatted: Font: Bold, No underline, Font color: Auto
“BIR” Bureau of Internal Revenue
Formatted: Font: Bold
“DOH” Department of Health
Environmental Compliance Environmental Compliance Certificate is a document issued by the Formatted: Font: Bold, No underline, Font color: Auto
Certificate “ECC” DENR/EMB after a positive review of an ECC application certifying that
Formatted: Font: Bold
the proposed project will not cause significant negative environmental
impact and the project proponent has complied with all the requirements Formatted: Font: Bold, No underline, Font color: Auto
of the Environmental Impact System, and has committed to implement its Formatted: Font: Bold
approved Environmental Management Plan
Management Discount Formatted: Font: Bold, No underline, Font color: Auto
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EXECUTIVE SUMMARY Formatted: Font: Bold
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The following summary is qualified in its entirety by, and should be read in conjunction with, the more
detailed information and audited financial statements, including notes thereto, found in the appendices
of this Prospectus.
Prospective investors should read this entire Prospectus fully and carefully, including the section on
“Risk Factors”. In case of any inconsistency between this summary and the more detailed information in
this Prospectus, then the more detailed portions, as the case may be, shall at all times prevail.
Core Business
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Business Strategies
RISK FACTORS
An investor should seek professional advice if he or she is uncertain of, or has not understood any aspect
of the securities to invest in or the nature of risks involved in buying of securities.
1. The following is a summary of all the risks that apply to the Issuer and/or this offering. You should
carefully consider these risks prior to investing in this offering.
Operating History:
The Issuer has limited or no operating history because the Issuer may have operated for only a short
period of time, it has produced little or no profit. There is no assurance that it will ever produce a
profit.
Difficulty to collect from patients (select all that apply): Check Box
Existing law penalizes the refusal of hospitals and medical clinics to administer appropriate initial
medical treatment and support in emergency or serious medical cases.
The Issuer has limited resources and will not be able to continue operating without the proceeds
from this offering. It is possible that the proceeds from this offering and other resources may not
be sufficient for the Issuer to continue to finance operations. The Issuer expects to continue to
experience losses from operations and it cannot be predicted when or if the Issuer will become
profitable. If the Issuer achieves profitability, it may not be sustainable.
The Issuer has incurred losses since inception and may incur future losses. The Issuer has not yet
generated a profit from operations. As of the date of the most recent financial statements, the
Issuer had an accumulated deficit of
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Key Personnel
The Issuer success depends substantially on the services of a small number of individuals Formatted Table
The Issuer may be harmed if it loses the services of these people and it is not able to attract and
retain qualified replacements
The Issuer’s officers, directors, managers and key persons will continue to have substantial
ownership and control over the Issuer after the offering
The Issuer does not maintain key person life insurance on those individuals on whom the
Issuer’s success depends. The loss of any of these individuals could have a substantial negative
impact on the Issuer and your investments.
Past Failures
Prior to organizing the Issuer, one or more of the Issuer’s officers, directors, and/or managers
operated a business in which shareholders lost part or all of their investment. The Issuer’s
ability to operate successfully may depend on its officers, directors, and/or managers to
succeed where they have failed before.
Government Regulations:
The Issuer must comply with local and national rules and regulations. If the Issuer fails to comply
with a rule or regulation it may be subject to fines or other penalties, or its permit or license may be
revoked or suspended. The Issuer may have to stop operation and you may lose your entire
investment.
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Dilution (select all that apply):
The price of a share in this offering is significantly higher than the book value of the securities.
By participating in this offering, you will incur immediate and substantial dilution of the book
value of your investment.
To the extent outstanding options or warrants to purchase securities are exercised, new
Investors will incur further dilution of the book value of their investment
There are no limits in place to restrict the Issuer’s ability to issue securities in the future. If the
Issuer issues additional securities, by participating in this offering you may experience further
dilution of the value of your investment.
No Existing Market
Because there is no market for the Issuer’s securities, you may not be able to sell your securities
or recover any part of your investment. You should not invest unless you can afford to hold
your investment indefinitely.
Offering Price
The offering price of the Issuer’s securities has been arbitrarily set and accordingly should not
be considered an indication of the actual value of the Issuer.
Best-effort Offering:
The Issuer is offering these securities on a “best-effort” basis. The Issuer has not contracted
with an underwriter, placement agent, or other person to purchase or sell all, or a portion of its
securities and there is no assurance that it can sell all or any of the securities.
Other Risks
Formatted Table
Risk relating to Hospital Business
Licenses, permits
Regulatory risks
Healthcare infections
Emergencies/disaster risks
Government discount programs/collection from Philhealth
Hazardous material events, e.g. chemical/radiological exposure
Physician litigation
Describe any other risks that apply to the Issuer and/or the offering that have not yet been address
above. Failure to disclose all material risks may subject the Issuer, its Officers, Directors, Managers
or promoters to liability for securities fraud..
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BUSINESS INFORMATION
Description of Business
2. Business of the Issuer and form of organization
2.
Describe in details the business of the Issuer
4. Operations
The Issuer (select all that apply):
Has never conducted operations
Is in the construction development stage
Is currently conducting operations
Has shown a profit in the last fiscal year
Briefly describe
5. Jurisdiction: Is the Issuer an entity organized and doing business in the Philippines?
_____Yes_____ No
Suppliers
The Issuer (select all that apply):
Has major supply contracts
Is currently or expects to be dependent upon a limited number of suppliers
Has no suppliers
Sources and availability of raw materials and the names of principal suppliers; If the registrant is or
is expected to be dependent upon one or a limited number of suppliers for essential raw materials,
energy or other items, describe. Describe any major existing supply contracts.
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Procurement Policy
Competition
Describe the competition that the Issuer faces, and how the Issuer intends to compete. If the Issuer
offers what it considers to be unique good or services, discuss competition from companies that
provide similar or substantial goods or services.
Name the Issuer’s principal competitors, and indicate their relative size and financial market
strengths. Describe the Issuer’s strategy, whether to compete by price, service, or some other basis
Marketing
Describe how the Issuer plans to market its products or services during the next 12 months, including
who will perform these marketing activities
Employees
Indicate whether or not any of them are subject to collective bargaining agreements (CBA) and the
expiration dates of any CBA. If the registrant’s employees are on strike, or have been in the past
three (3) years, or are threatening to strike, describe the dispute. Indicate any supplemental benefits
or incentive arrangements the registrant has or will have with its employees;
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Outsourced
Clerical
Others
Medical Practitioners
Briefly describe the qualifications and criteria to qualify. Disclose the current number of medical
practitioners and its expected number within the next 12 months.
Properties
Describe briefly any material pending legal proceedings to which the registrant or any of its
subsidiaries or affiliates is a party or of which any of their property is the subject. Include the name of
the court or agency in which the proceedings are pending, the date instituted, the principal parties
thereto, a description of the factual basis alleged to underlie the proceeding and the relief sought.
Include similar information as to any such proceedings known to be contemplated by governmental
authorities or any other entity.
Provide details
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Government Regulation (select all that apply):
The Issuer and/or its products/services are subject to material regulation by a government
agency.
The Issuer is required to have a license or permit (other than organizational license) to conduct
business.
The Issuer has obtained any required licenses or permits to conduct business.
Formatted Table
Need for any government approval of principal products or services. If government approval is
necessary and the registrant has not yet received that approval, discuss the status of the approval
within the government approval process
Provide information on hospital departments and their functions. Include personnel overview per
department and their functions.
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USE OF PROCEEDS
Net Proceeds
8. The net proceeds of the offering for the minimum and maximum offering amounts are as follows:
Provide a detailed breakdown on how the Issuer intends to use the net offering proceeds. Include the
repayment of debt, payment to officers, directors and related parties and any purchase of assets.
TOTAL
Where less than all of the securities to be offered may be sold and more than one use is listed for the
proceeds, the registrant shall indicate the order of priority of such purposes and discuss its plans if
substantially less than the maximum proceeds are obtained.
If any material amounts of other funds are necessary to accomplish the specified purpose(s) for which
the offering is made, the registrant shall state the amounts and sources of such other funds needed.
If the proceeds will be used to pay-off existing debt, disclose the following: ______ Not Applicable
TOTAL
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Description of the debt
Is the debtor related to the Issuer or any of its Directors or Officers?_____Yes _____No
If the answer to any of the above is "yes", disclose the relationship between each person and the
issuer and the principal terms of each transaction. If assets were acquired from a person, disclose the
cost of the asset to the issuer and the method used to determine this cost. Disclose for each person
who has been involved in more than one related party transaction, their relationship with the issuer
and which of the transactions they have been involved with.
Ifs the proceeds will be used to purchase real estate property? _________Yes _____No____Not Applicable
(Provide information on each property acquired)
Description of Property
Name of Seller
Acquisition Cost
Terms of Payment
If the answer to any of the above is "yes", disclose the relationship between each person and the
issuer and the principal terms of each transaction. If assets were acquired from a person, disclose the
cost of the asset to the issuer and the method used to determine this cost. Disclose for each person
who has been involved in more than one related party transaction, their relationship with the issuer
and which of the transactions they have been involved with.
If any material amount of the proceeds is to be used to acquire assets or finance the acquisitions of
other businesses, describe the assets or businesses and identify the persons from whom they will be
bought. State the cost of the assets and, where such assets are to be acquired from affiliates of the
registrant or their associates, give the names of the persons from whom they are to be acquired and set
forth the principle followed in determining the cost to the registrant.
If the proceeds will be used for the construction of the hospital, provide the following:
Project Name
Project Cost (Estimate)
Schedule of Disbursement
Target Completion Date
Percentage Completed
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9. If proceeds to this offering is not sufficient to fund the intended use, where will the company source
the additional funding? _____ Not Applicable
10. The securities being offered are (select all that apply):
Founder’s Shares
Common Shares
Preferred Shares
Others (specify):
(a) State the amount of capital stock of each class issued or included in the shares of stock to be
offered:
(b) If the registrant is offering com mon equity, describe any dividend, voting and preemption
rights.
(c) If the registrant is offering preferred stock, describe the dividend, voting, conversion and
liquidation rights as well as redemption or sinking fund provisions.
(b) Describe any provision in the charter or by-laws that would delay, defer or prevent a change in
control of the registrant.
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12. Source of the aforementioned shares offered for sale (select all that apply):
Primary (from the unissued portion of the Authorized Capital Stock)
Secondary Selling Shareholders
Formatted: Indent: Left: 0"
Secondary Offering
13. If any of the securities to be registered are to be offered for the account of shareholder, name each
such security holder, indicating the following: _____ Not Applicable
Class of
Name of Selling No. of Shares
Securities Offer Price Issue Value
Shareholder Offered for Sale
Offered
15. Are these securities are to be registered under a delay or continuous offering?
______Yes _______No
Furnish the following information as to all securities of the registrant sold by it within the past three (3)
years which were not registered under the Code. Include sales of reacquired securities, as well as new
issues, securities issued in exchange for property, services, or other securities, and new securities
resulting from the modification of outstanding securities. Indicate whether the issuer received written
confirmation from the Commission under SRC Rule 10.1 that such exemptive relief from registration
was available and, if so, the date such confirmation was issued:
Exemption from
Class of Securities Sold Purchasers Consideration
Registration Claimed
Discuss the various factors considered in determining the offering price of the securities for
registration.
The following factors may be relevant to the price at which the securities are being offered: after-tax
earnings, price/earnings multiple, net tangible bookvalue per share.
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Dilution
Where common equity securities are being registered and there is a substantial disparity between
the public offering price and the effective cash cost to officers, directors, promoters and affiliated
persons of common equity acquired by them in transactions during the past five (5) years, or which
they have the right to acquire, and the registrant is not subject to the reporting requirements of
Section 17 of the Code immediately prior to filing of the registration statement, there shall be
included a comparison of the public contribution under the proposed public offering and the
effective cash contribution of such persons. In such cases, and where common equity securities are
being registered by a registrant that has had losses in each of its last three fiscal years, or from
inception if shorter, and there is a material dilution of the purchasers' equity interest, the following
shall be disclosed:
(1) The net tangible book value per share before and after the distribution. For this purpose, net
tangible book value means total assets (exclusive of copyrights, patents, goodwill, research
and development costs, pre-operating costs, and similar intangible assets) minus total
liabilities.
(2) The amount of the increase in such net tangible book value per share attributable to the cash
payments made by purchasers of the shares being offered; and
(3) The amount of the immediate dilution from the public offering price which will be absorbed
by such purchasers.
The following does not purport to be a complete listing of all the rights, obligations, and privileges
attaching to or arising from the Offer Shares. Some rights, obligations, or privileges may be further
limited or restricted by other documents and subject to final documentation. Prospective investors are
enjoined to perform their own independent investigation and analysis of the Company and the Offer
Shares. Each prospective investor must rely on its own appraisal of the Company and the Offer Shares
and its own independent verification of the information contained herein and any other investigation it
may deem appropriate for the purpose of determining whether to invest in the Offer Shares and must not
rely solely on any statement or the significance, adequacy, or accuracy of any information contained
herein. The information and data contained herein are not a substitute for the prospective investor’s
independent evaluation and analysis.
Applications ………………………………….
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Restrictions on the Issuance and
Disposal of shares ………………………..
Trading of Shares …………………………
Documentary requirements:
Investor Restrictions
The aggregate amount of securities purchased from one or more Issuers offering or selling securities under
the registration statement during the 12-month period preceding the date of the sale, together with the
securities to be sold by the Issuer to the Investor:
17. Is the offering subject to any other Investor restrictions? _____ Yes _____ No
18. Are the securities subject to any other resale restrictions by the Issuer? _____ Yes _____ No
Securities Certificates
19. Will the Issuer issue physical securities certificates in this Offering? _____ Yes _____ No
PLAN OF DISTRIBUTION
21.19. List the persons or companies who will offer and sell the securities on behalf of the Issuer:
Compensation
Relationship received for
Name Address Tel. No.
to Issuer selling
securities
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Compensation
Relationship received for
Name Address Tel. No.
to Issuer selling
securities
Outline briefly the plan of distribution of any securities to be registered. that are to be offered otherwise
than through underwriters.
22. Will the Issuer engage the service of an underwriter? _____ Yes _____ No
23. State how the securities will be sold
24. Jurisdiction where the securities are being distributed/offered for sale:
___________________________________.
CAPITALIZATION
Capital Stock
Outstanding Securities
26.20. For each class of the Issuer’s securities, indicate the total number of outstanding securities
and the total number of securities of the Issuer is authorized to issue. Also, include a
description of each class of securities.
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Securities the Issuer is
Class of Securities Securities Outstanding
Authorized to Issue
TOTAL
Description of Securities
Resale Restrictions
27. Are there any resale restrictions on the Issuer’s outstanding securities? _____ Yes _____ No
Describe restrictions
28. List the total number of securities reserved or subject to issuance under outstanding
securities purchase agreement, stock options, warrants or rights. _____ None _____ Not
Applicable
TOTAL
29. Does the Issuer plan to issue or offer options in the future? _____ Yes _____ No
Stockholders
Original Stockholders
30.21. Provide the names of the original stockholders, class of securities, number of shares held
and percentage of total shares held over outstanding shares.
No Name Class of Securities Shares Held %
1
2
3
4
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No Name Class of Securities Shares Held %
5
6
7
8
TOTAL
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Current Stockholders
31.22. Provide the names of the current stockholders, class of securities, number of shares held
and percentage of total shares held over outstanding shares. ____ Same as Above
Top 20 Stockholders
32.23. Provide the names of the Top Twenty (20) principal shareholders who beneficially owns
at least 10% interest of each class of securities in the Issuer.
Class of Number of Share
No Name %
Securities Held
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
TOTAL
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Dividends and Dividend Policy
33.24. Dividends and DividendPolicy
(a) Discuss any cash dividends declared on each class of its common equity by the registrant for
the two most recent fiscal years and any subsequent interim period for which financial
statements are required to be presented by SRC Rule 68 if applicable..
(a) Describe any restriction that limits the ability to pay dividends on common equity or that are
likely to do so in the future.
BOARD OF DIRECTORS
Directors
34.25. The table below sets forth each member of the Board of Directors of the Issuer as of the date
of the Prospectus:
Year
No Name Age Position Citizenship
Appointed
1 Chairman Filipino
2 Vice Chairman Filipino
3 Director Filipino
4 Director Filipino
5 Director Filipino
6 Director Filipino
7 Director Filipino
8 Director Filipino
9 Director Filipino
10 Director Filipino
11 Director Filipino
912 Director Filipino
Independent
13 Filipino
Director
Independent
14 Filipino
Director
101 Independent
Filipino
5 Director
2 Formatted: Centered
3 Formatted: Centered
4 Formatted: Centered
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No Name Business and/or Professional Work Experience Formatted Table
5 Formatted: Centered
6 Formatted: Centered
7 Formatted: Centered
8 Formatted: Centered
9 Formatted: Centered
10 Formatted: Centered
11 Formatted: Centered
12 Formatted: Centered
13 Formatted: Centered
14 Formatted: Centered
15 Formatted: Centered
The following table shows the security ownership of directors in the common shares of the
Company as of____________________2017.
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Filipino
Filipino
Filipino
Filipino
Filipino
MANAGEMENT
Name
Age
Title
Time spent on Issuer’s business (Indicate if Part Time or Full Time)
Hospital affiliation – 5 years
Education
Name
Age
Title
Time spent on Issuer’s business (Indicate if Part Time or Full Time)
Hospital affiliation – 5 years
Education
Name
Age
Title
Time spent on Issuer’s business (Indicate if Part Time or Full Time)
Hospital affiliation – 5 years
Education
The following table shows the security ownership of management in the common shares of the
Company as of ____________________20x x.
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Direct Indirect
Compensation
38.29. List the compensation paid by the Issuer to the Chief Executive Officers and four (4) most highly
compensated officers other than the CEO, all of whom shall be individually named during the last fiscal
year:
Annual Compensation
_____________________________________________________________________________________________________________________
(a) (b) (c) (d) (e)
Name and Other Annual
Principal position Year Salary (P) Bonus (P) Compensation
______________________________________________________________________________________________________________________
CEO _____
_____
A ______
______
B ______
______
C ______
______
D ______
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Owes compensation for prior years
Has worked for or managed a company in the same type of business of the Issuer
Has managed another compensatory plan or arrangement, including payments to be received from
the Issuer, with respect to a named executive officer
filed against
,Administra-
proceeding,
yearsBankr
petition for
him, within
or has such
insolvency
Has filed a
D = Director
a petition
uptcy
ID –
Civil
tive
(5)
Name Case Details Formatted: Centered, Indent: Left: 0.08", Right: 0.08"
Independent
Formatted: Centered
Director
O - Officer Formatted Table
Formatted: Font: Bold
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Certain Legal Proceedings
This section applyThis section applies to:
The issuer, its subsidiaries and affiliates
All Directors and Officers of the Issuer
All Beneficial Owners of 10% or more of the Issuer’s outstanding voting equity and
All Promoters of the Issuers
42.33. Have any of the above-listed persons filed or subject of any bankruptcy petition filed by or
against any business of which such person was a general partner or executive either at the time of
the bankruptcy or within two (2) years prior to that time. [ ] Yes [ ] No
43.34. Have any of the above-listed persons been named as the subject of a pending felony or
misdemeanor criminal proceeding excluding traffic violations or other minor offenses not related to
fraud or a financial crime? [ ] Yes [ ] No
44.35. Have any of the above-listed persons been the subject of an order, judgment, decree, sanction or
administrative findings imposed by any government agency, administrative agency, self-regulatory
organization, civil court, or administrative court in the last five (5) years related to his or her
involvement in any type of business, securities, insurance, or banking activity? ? [ ] Yes [ ] No
45.36. Are any of the above-listed persons the subject of a pending civil, administrative, or self-
regulatory action related to his or her involvement in any type of business, securities, insurance, or
banking activity? ? [ ] Yes [ ] No
46.37. Has any civil action, administrative proceeding, or self-regulatory proceeding been threatened
against any of the above-listed persons related to his or her involvement in any type of business,
securities, insurance or banking activity? [ ] Yes [ ] No
Litigation
47.38. The Issuer (select all that apply):
Has been involved in litigation or subject to administrative action in the last five (5) years that has
had a material effect upon the Issuer’s business, financial condition or operations
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Has pending litigation or administrative action that may have a material effect upon the Issuer’s
business, financial condition, or operations
Is currently threatened by litigation or administrative action that may have a material effect upon
the Issuer’s business, financial condition, or operations
None of the above
Family Relationship
49.39. Describe any family relationships up to the fourth civil degree either by consanguinity or affinity
among directors, executive officers, or persons nominated or chosen by the registrant to become
directors or executive officers.
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FINANCIAL INFORMATION
Registrants that have not had revenues from operations in each of the last two fiscal years, or the last
fiscal year and any interim period in the current fiscal year for which financial statements are
furnished in the disclosure document, shall in addition to applicable items under subparagraph (2),
provide the information in subparagraph (1) hereof.
Describe the plan of operation for the next twelve (12) months. This description should
include such matters as:
(a) a discussion of how long the registrant can satisfy its cash requirements and
whether it will have to raise additional funds in the next twelve (12) months;
(b) a summary of any product research and development that the registrant will
perform for the term of the plan;
(c) any expected purchase or sale of plant and significant equipment; and
MD&A helps explain financial results. A reader of the MD&A should understand the financial
results of the registrant’s business as discussed in the “Business” section. It shall provide
information with respect to liquidity, capital resources and other information necessary to
understanding the registrant’s financial condition and results of operation.
The discussion and analysis shall focus specifically on material events and uncertainties known
to management that would cause reported financial information not to be necessarily indicative
of future operating results or of future financial condition. This would include descriptions and
amounts of matters that would have an impact on future operations and have not had an impact
in the past, and matters that have had an impact on reported operations and are not expected to
have an impact upon future operations.
For both full fiscal years and interim periods, disclose the company’s and its majority-owned
subsidiaries’ top five (5) key performance indicators. It shall include a discussion of the manner
by which the company calculates or identifies the indicators presented on a comparable basis.
Discuss the registrant's financial condition, changes in financial condition and results of
operations for each of the last three fiscal years. If the registrant’s financial statement
shows losses from operations, explain the causes of these losses and the steps the
registrant has taken or is taking to address these causes. This discussion should address
the past and future financial condition and results of operation of the registrant, with
particular emphasis on the prospects for the future. The discussion should also address
those key variable and other qualitative and quantitative factors which are necessary to
an understanding and evaluation of the registrant. If material, the registrant should
disclose the following:
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uncertainties that will result in or that are reasonably likely to result in the
registrant’s liquidity increasing or decreasing in any material way. The
registrant shall indicate balance sheet conditions or income or cash flow items
that it believes may be indicators of its liquidity condition. The following
conditions shall be indicated: whether or not the registrant is having or
anticipates having within the next twelve (12) months any cash flow or
liquidity problems; whether or not the registrant is in default or breach of any
note, loan, lease or other indebtedness or financing arrangement requiring it to
make payments; whether or not a significant amount of the registrant’s trade
payables have not been paid within the stated trade terms. If a material
deficiency is identified, the course of action that the registrant has taken or
proposes to take to remedy the deficiency should also be indicated. The
registrant should identify and separately describe internal and external sources
of liquidity, and briefly discuss any sources of liquid assets used.
(ii) Any events that will trigger direct or contingent financial obligation that is
material to the company, including any default or acceleration of an obligation;
(iv) Any material commitments for capital expenditures, the general purpose of
such commitments, and the expected sources of funds for such expenditures
should be described;
(v) Any known trends, events or uncertainties that have had or that are reasonably
expected to have a material favorable or unfavorable impact on net sales or
revenues or income from continuing operations should be described. If the
registrant knows of events that will cause material change in the relationship
between costs and revenues (such as known future increases in cost of labor or
materials or price increases or inventory adjustments), the change in the
relationship shall be disclosed.
(vi) Any significant elements of income or loss that did not arise from the
registrant's continuing operations;
(vii) The causes for any material change from period to period which shall include
vertical and horizontal analyses of any material item;
The term “material” in this section shall refer to changes or items amounting to
five percent (5%) of the relevant accounts or such lower amount, which the
registrant deems material on the basis of other factors.
(viii) Any seasonal aspects that had a material effect on the financial condition or
results of operations.
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Summary Financial Information
Prospective purchasers of the Offer should read the summary financial data below together with the
financial statements, including the notes thereto, included in this Prospectus and “Management's
Discussion and Analysis of Results of Operations and Financial Condition”. The summary financial data
for the _________ year ended ___________ and ________ are derived from the audited financial statements of
_____________, including the notes thereto. The detailed financial information for the _______ years ended
________ are found on page ________ Prospectus and the _______ months ended _____________ are found on page
_______ Prospectus.
The summary of financial and operating information of ___________ presented below as of and for the years
ended _________________ were derived from the consolidated financial statements of ___________, audited by
_______________________________and prepared in compliance with the Philippine Financial Reporting
Standards (“PFRS”). The financial and operating information of ___________ presented below as of and for
the _______months ended ______________________ were derived from the unaudited consolidated financial
statements of _________ prepared in compliance with Philippine Accounting Standards (“PAS”) 34, “Interim
Financial Reporting” and reviewed by ______________. in accordance with Philippine Standards on
Reviewing Engagements (“PSRE”) 2410, “Review of Interim Financial Information performed by the
Independent Auditors of the Entity.” The information below should be read in conjunction with the
consolidated financial statements of __________________ and the related notes thereto, which are included in
____________ of this Preliminary Prospectus. The historical financial condition, results of operations and
cash flows of ______________ are not a guarantee of its future operating and financial performance.
(Audited) (Audited)
(in millions except per share figures or where otherwise
indicated)
Consolidated Statements of Income Data
(Audited) (Audited)
20______ 20______ 20______ 20______
Consolidated Statements of Financial
Position Data
(Audited) (Audited)
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Information on Independent Accountant and other Related Matters
53.43. The Issuer has no disagreement with its external auditor on any matter regarding (select all that
apply):
Accounting principles or practices
Financial statement disclosures
Auditing scope or procedure
(a) If during the registrant's two most recent fiscal years or any subsequent interim period, an
independent accountant who was previously engaged as the principal accountant to audit the
registrant's financial statements, or an independent accountant who was previously engaged to
audit a significant subsidiary, ceased performing services for registrant, disclose the name of the
previous accountant or the handling partner in case of a firm, reason/s for the cessation of
service and the date of his resignation, dismissal or cessation of performing services for
registrant.
(b) Describe disagreements, if there were any, with the former accountant on any matter of
accounting principles or practices, financial statement disclosure, or auditing scope or procedure
which, if not resolved to the satisfaction of the former accountant, would have caused it to make
reference to the subject matter of the disagreement(s) in connection with its report.
(c) If there were any disagreements as described in subparagraph (2), the registrant shall request
the former accountant to furnish the registrant with a letter addressed to the Commission stating
whether it agrees with the statements made by the registrant and, if not, stating the respects in
which it does not agree. The registrant shall file the former accountant's letter as an exhibit to the
report or registration statement containing this disclosure
Taxation
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INDEPENDENT AUDITORS AND COUNSELS
All legal opinions/matters in connection with the issuance of each Offer will be passed upon by
___________________ for the Company. ___________________________ have no direct interest in the Company.
_____________________________________ may from time to time be engaged to advise in the transactions of the
Company and perform legal services on the basis that ________________________ provide such services to its
other clients.
Independent Auditors
The consolidated financial statements of the Company as at and for the years ended have been audited by
_______________________________, independent auditors, in accordance with Philippine Standards on Auditing
as set forth in their report thereon appearing elsewhere in this Prospectus.
The Audit Committee of the Company, reviews and monitors, among others, the integrity of all financial
reports and ensures compliance with both internal financial management manual and pertinent
accounting standards, including regulatory requirements. The Audit Committee also performs the
following duties and responsibilities relating to the services of the Company’s external auditors:
There is no arrangement that experts and independent counsels will receive a direct or indirect interest
in the Issuer or was a promoter, underwriter, voting trustee, director, officer, or employee of the Issuer.
REGULATORY FRAMEWORK
LGUs exercise police power through their respective legislative bodies. Specifically, the LGU, though its
legislative body, has the authority to enact such ordinances as it may deem necessary and proper for
sanitation and safety, the furtherance of the prosperity, and the promotion of the morality, peace, good
order, comfort, convenience, and general welfare of the locality and its inhabitants. Ordinances can
reclassify land, order the closure of business establishments, and require permits and licenses from
businesses operating within the territorial jurisdiction of the LGU.
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Zoning and Land Use
LGUs are authorized under the Local Government Code to enact zoning ordinances. These ordinances
may restrict or limit the zoning and land use of parcels of land within the locality. LGUs may classify
parcels of land as commercial, industrial, residential or agricultural. A procedure for change of land use is
allowed, although the process may be lengthy and cumbersome.
Land classified for agricultural purposes as of or after June 15, 1988, cannot be converted to non-
agricultural use without the prior approval of DAR.
Property Registration
The property registration system of the Philippines confirms land ownership and is binding on all
persons, including the Government. Once registered, title to the parcel of land can no longer be
challenged unless it involves claims noted on the certificate of title. Title to registered lands may not be
lost through adverse possession or prescription. The Property Registration Decree (P.D. 1529), as
amended, codified the laws relative to land registration and is based on the generally accepted principles
underlying the Torrens System.
Transfers or encumbrances on the parcel of land must be registered in the system, to bind third persons.
A subsequent registration and a new Transfer Certificate of Title will be issued upon presentation of
documents and settlement of taxes and fee. All documents evidencing conveyances of the subdivision
should also be registered with the Register of Deeds. Title to the subdivision must be delivered to the
purchaser upon full payment of the purchase price.
Property Taxation
Real property taxes are payable annually based on the property’s assessed value, which vary depending
on the location, use and the nature of the property. Under the Local Government Code, real property tax
must not exceed 2.0% of the assessed value in municipalities and cities within Metro Manila or in other
chartered cities and 1.0% in all other areas. An additional special education fund tax of 1.0% of the
assessed value of the property is also levied annually.
PhilHealth is a government corporation attached to the Department of Health of the Philippines (“DOH”)
that ensures sustainable, affordable and progressive social health insurance pursuant to the provisions of
RA 7875 or the National Health Insurance Act of 1995. Employers are required to ensure enrollment of
its employees in a National Health Program being administered by the PhilHealth.
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Department of Labor and Employment
Department of Labor and Employment stands as the national government agency mandated to formulate
policies, implement programs and services, and serve as the policy-coordinating arm of the Executive
Branch of the Government in the field of labor and employment. The Department has exclusive authority
in the administration and enforcement of labor and employment laws and such other laws as specifically
assigned to it or to the Secretary of Labor and Employment.
Department of Health
The Toxic Substances and Hazardous and Nuclear Waste Control Act of 1990 regulates, restricts or
prohibits the (i) importation, manufacture, processing, handling, storage, transportation, sale,
distribution, use and disposal of chemical substance and mixtures that present unreasonable risk or
injury to health or the environment, and (ii) entry into the Philippines or the keeping in storage of
hazardous wastes which include by-products, process residue, contaminated plant or equipment or other
substances from manufacturing operations. Said Act is implemented by the DENR.
The Ecological Solid Waste Management Act of 2000 provides for the proper management of solid waste
which includes discarded commercial waste and non-hazardous institutional and industrial waste. Said
Act prohibits, among others, the transporting and dumping of collected solid wastes in areas other than
such centers and facilities prescribed thereunder. The National Solid Waste Management Commission,
together with other government agencies and the different local government units, are responsible for
the implementation and enforcement of the said law.
The Sanitation Code provides for sanitary and structural requirements in connection with the operation
of certain establishments such as food establishments which include such places where food or drinks
are manufactured, processed, stored, sold or served. Under the Sanitation Code, food establishments are
required to secure sanitary permits prior to operation which shall be renewable on a yearly basis. Said
Code is implemented by the DOH.
The EIS refers to both the document and the study of a environmental impact of the project, including a
discussion of the scoping agreement identifying critical issues and concerns as validated by the EMB,
environmental risk assessment if determined necessary by EMB during the scoping, environmental
management program, direct and indirect consequences to human welfare and the ecological as well as
environmental integrity. The IEE refers to the document and the study describing the environmental
impact, including mitigation and enhancement measures, for projects in environmentally critical areas.
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While the terms and conditions of an EIS or an IEE may vary from project to project, as a minimum it
contains all relevant information regarding the project’s environmental effects. The entire process of
organization, administration and assessment of the effects of any project on the quality of the physical,
biological and socio-economic environment as well as the design of appropriate preventive, mitigating
and enhancement measures is known as the EIS System. The EIS System successfully culminates in the
issuance of an ECC. The issuance of an ECC is a Philippine government certification that the proposed
project or undertaking will not cause a significant negative environmental impact; that the proponent has
complied with all the requirements of the EIS System; and that the proponent is committed to
implementing its approved Environmental Management Plan in the EIS or, if an IEE was required, that it
shall comply with the mitigation measures provided therein before or during the operations of the
project and in some cases, during the abandonment phase of the project.
Project proponents that prepare an EIS are required to establish an Environmental Guarantee Fund when
the ECC is issued for projects determined by the DENR to pose a significant public risk to life, health,
property and the environment or where the project requires rehabilitation or restoration. The
Environmental Guarantee Fund is intended to meet any damage caused by such a project as well as any
rehabilitation and restoration measures. Project proponents that prepare an EIS are required to include a
commitment to establish an Environmental Monitoring Fund when an ECC is eventually issued. In any
case, the establishment of an Environmental Monitoring Fund must not occur later than the initial
construction phase of the project. The Environmental Monitoring Fund must be used to support the
activities of a multi-partite monitoring team, which will be organized to monitor compliance with the ECC
and applicable laws, rules and regulations.
Said Act require owners or operators of facilities that discharge regulated effluents (such as wastewater
from manufacturing plants or other commercial facilities) to secure a discharge permit from the DENR
which authorizes said owners and operators to discharge waste and/or pollutants of specified
concentration and volumes from their facilities into a body of water or land resource for a specified
period of time.
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Regulation of Healthcare Professionals
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Other laws
The members of the Board Corporate Governance Committees were elected during the ________________
meeting of the Company on ___________________________.
Chairman
Member
Member
Independent
Director
Independent
Director
Corporate Governance
The following information, as declared and approved by the Board of Directors of the company, shall
be discussed:
(a) The evaluation system established by the company to measure or determine the level of
compliance of the Board of Directors and top-level management with its Manual ofCorporate
Governance;
(b) Measures being undertaken by the company to fully comply with the adopted leading
practices on good corporate governance;
(c) Any deviation from the company’s Manual of Corporate Governance. It shall include a
disclosure of the name and position of the person/s involved, and the sanction/s imposed on
said individual;
Describe any other material factors that will or could affect the Issuer or its business or which are
necessary to make any other information in this Statement not misleading or incomplete.
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Formatted Table
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