Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

National Capital Region

APPLICATION FOR LICENSE

PRIVATE RECRUITMENT AND PLACEMENT AGENCY
NAME OF AGENCY: ___________________________________________________ TIN No. _______________
ADDRESS O AGENCY: ________________________________________________________________________
TEL NOS.: ___________________________________________________________________________________
TYPE OF BUSINESS ORGANIZATION: (please check)
( ) Sole Proprietorship

( ) Partnership

( ) Corporation

Date of Registration ____________________________________ Registration No.: __________________________

COMPREHENSIVE DESCRIPTION OF OPERATION:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
MANAGEMENT: PRINCIPAL OFFICERS/MANAGING PARTNERS
NAME
DESIGNATION

ADDRESS

FINANCE:
Total Assets
: ____________________________________Paid-in-Capital _____________________________
Total Liabilities : ____________________________________Date of Statement: __________________________
Networth
: ____________________________________
UNDERTAKING:
That I, _________________________________, Filipino, of legal age, ____________________________
(Name)
(Position)
of ______________________________________________________________, after having been duly sworn to in
(Company)
Accordance with law, do hereby depose and say:
That our company will not engage in the recruitment of children below 15 years or place children below 18
years old in hazardous occupation in accordance with Republic Act No. 9231 (An Act Providing for the Elimination
of the Worst Forms of Child Labor and Affording Stronger Protection for the Working Child), amending Republic
Act No. 7610 and Republic Act No. 7658; Republic Act No. 9208 (Trafficking of Child and Women).
That our company will assume full responsibility for all claims and liabilities which may arise in
connection with the use of the license.
In witness whereof, I have hereunto affixed my signature this ________ day of _____________________,
20 ___ in the City of _____________________.

_________________________________
(Affiants Name/Signature)
SUBSCRIBED AND SWORN to before me this ________ day of _____________________, 20__ in
_________________, Affiant exhibited to me his/her Residence Certificate No. __________issued at
________________ on ____________________________
NOTARY PUBLIC
Doc. No. _________
Page No. _________
Book No. _________
Series of __________