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With The: Application For Contractor'S License Philippine Contractor'S Accreditation Board
With The: Application For Contractor'S License Philippine Contractor'S Accreditation Board
101
The following pertinent documents and information are to be submitted in support of the license application of said firm:
Checklist for New License Application A. Legal
APPLICATION FOR CONTRACTOR'S LICENSE with the PHILIPPINE CONTRACTOR'S ACCREDITATION BOARD
[ ] 1.1 For Sole Proprietorship: Certified true copy of BTRCP Certificate of Registration with pertinent BTRCP Form No. 16; For Partnership or Corporation: Certified true copy of SEC Certificate of Registration and Articles of Partnership/Incorporation and By-Laws showing Construction as Primary Purpose and subsequent amendments thereto; [ ] 2. Authorized Managing Officer (AMO) Nomination: [ ] 2.1 AMO Affidavit (PCAB Form No. 103) with a passport size picture of AMO; For corporations only: Original Corp. Secretary's certificate as to the nomination of the AMO (PCAB Form No. 104); [ ] 2.2 Original NBI clearance of Filipino AMO; [ ] 2.3 If AMO is Non-Filipino (in addition to 2.1): [ ] 2.3.1 Working visa [ ] 2.3.2 Alien Certificate of Registration; [ ] 2.3.3 NBI clearance if AMO has resided in the Philippines for six (6) months or longer if not,
Note:
equivalent clearance from AMO's home country duly authenticated by the Philippine embassy.
For Corporations or Associations with foreign shareholders, the following documents must be submitted: 1. Corporate Secretarys 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 must not exceed the percentage of foreign shareholdings. [ ] 3. Financial Statements dated within the last six (6) months immediately preceding the filing of application (duly audited and signed on every page by an Independent and PRC-BOA accredited external auditor) and a diskette/CD (compact disc) containing the firms Audited Balance Sheet & Income Statement in the prescribed template (PCAB Financial Statement Forms A & B downloadable from the DTI website at www.dti.gov.ph together with pertinent application forms). [ ] 3.1 For old companies, copy of the Quarterly or Annual Income Tax Return certified true by the BIR, covering the income reported in the Audited Income Statement submitted for the quarter or taxable year immediately preceding the filing of application, whichever is applicable; [ ] 3.2 Cash :Original copy of Bank Certification/Bank statement of account certified by Bank Manager of cash deposits as of the Balance Sheet date; [ ] 3.2.1 Authorization to Depository Bank (PCAB Form No. 105); [ ] 3.3 List of Land and Building/s owned by the company and registered in its name (PCAB Form No. 106a); [ ] 3.3.1 Certified true copy of TCT including back page; [ ] 3.3.2 Deed of Sale or Certified True Copy (CTC) of Tax Declaration of Land / Bldg., owned by the firm. [ ] 3.4 List of Construction and/or Transportation/Delivery Vehicles/Equipment/Machineries/Plants owned by the company and registered in its name (PCAB Form No. 106b); [ ] 3.4.1 Certified true copy by the LTO of the LTO Certificate of Registration and current Official Receipt of Registration of registrable Construction and/or Transportation/Delivery Vehicles/Equipment reported; [ ] 3.4.2 Certified true copy of Deed of Sale or sales invoices/official receipts for non-registrable construction equipment/machineries/plants; [ ] 3.5 Additional documents to be submitted only if the values of each of the applicant's Inventories and Receivables Accounts exceed more than 20% of the contractors Networth, otherwise, the amount in excess of said account shall be deducted from networth. [ ] 3.5.1 Schedule of Inventories. (PCAB Form 107); [ ] 3.5.2 Schedule of Receivables. (PCAB Form 107); [ ] 4. Authorization to BIR & other agencies (PCAB Form No. 105a);
C.
B.
Financial
Note: (Amount in excess of of 1% of the minimum networth required for category applied for or P 50,000.00 whichever is higher, reflected as Cash or Cash on Hand will be deducted from the networth, If insupported.)
[ ] 5. List of Sustaining Technical Employee/s - STE (PCAB Form No. 106c) supported by the following documents for each STE: [ ] 5.1. STE Affidavit/s (PCAB Form No. 108) with a passport size picture/s of the nominated STE/s; [ ] 5.1.1 Certified true copy by PRC of valid PRC ID of STE as licensed professional or original Certification of Good Standing from PRC; [ ] 5.1.2 Original NBI Clearance/s of newly nominated STE/s; [ ] 5.2 STE Affidavit/s of Construction Experience (PCAB Form No. 109); [ ] 5.3 Personal Appearance Form duly accomplished and signed by the STE/s appearing before the designated officer of the PCAB or the nearest DTI regional/provincial office (PCAB Form No. 110) D. Original Signature of AMO on each and every page of the application forms including
Technical
supporting documents (except item 5.3) 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; AMO/Applicants for TRADE category may no longer be required to take the AMO examinations. Photocopies of documents, in lieu, of certified copies are accepted provided the original copies are presented for authentication Checklisted by: ________________________________ Signature Over Printed Name/Date
DO NOT FILL (For PCAB use only) Total No. of Pages Submitted: _______ [ ] Self-stamped envelopes * (no. ______ )
In behalf of ____________________________________________________________, (Name of Firm) I hereby request that its application for Contractor's License be approved. 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. 4. the evaluation of my application's qualification shall be solely based on the documents submitted at the time the application was filed/accepted by PCAB.
Republic of the Philippines) ______________________)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._______________;
GENERAL INFORMATION
A. CONTRACTORS IDENTIFICATION Name of Firm: Office Address: Tel./Fax No.:
Tel./Fax No.:
Website:
E-mail Address:
Type of Organization (Please Check):. [ ] Corporation [ ] Partnership SEC/BTRCP Registration No.: SSS Employers I.D.No.: CATEGORY APPLIED FOR ______________
[ ] Sole Proprietorship
Date of Registration:
APPLIED FOR:
CLASSIFICATION/S
B. OWNERS/STOCKHOLDERS/OFFICERS* (For Corporation, Partnership and Joint Venture) Capital Name Position Nationality Subscription
Paid-Up Capital
C. DIRECTORS / OFFICERS Name Position Nationality Tax Identification No. for Filipinos/ Passport No. for Foreigners
) ) S.S.
AMO AFFIDAVIT
I, __________________________________________________________________________________________, Filipino, of legal age, born on ____________________________________________________________ single/married to ________________________________________________________________________________________________ and residing at __________________________________________________________________________ having duly sworn in accordance with law depose and say: 1. That I am the Authorized Managing Officer (AMO) of ________________________________________ empowered to render general management and administrative decisions. 2. That I possess the following educational qualifications:
NAME OF SCHOOL ADDRESS DEGREE EARNED INCLUSIVE DATES OF ENROLLMENT LAST NAME FIRST NAME COMPLETE MAIDEN NAME LAST NAME FIRST NAME COMPLETE MIDDLE NAME
3. That I possess at least two (2) years of experience in the construction industry as follows (Sec. 20, R.A. 4566):
POSITION
COMPANY/ NATURE OF BUSINESS
ADDRESS
JOB DESCRIPTION
DATES OF 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 (Sec. 20, RA 4566):
TRAINING/SEMINAR CONDUCTED BY ADDRESS INCLUSIVE DATES OF TRAINING
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 (Rule 4, Section 4.2) 6. That I have not been convicted by a court of competent jurisdiction of any offense involving moral turpitude (Rule 4, Section 4.2) 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 (For corporations and partnerships only) 8. That I authorize the PCAB to verify and investigate any or all information in this instrument from whatever sources PCAB may consider appropriate; 9. 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 _________________, 200 ___ affiant exhibited his/her Community Tax Certificate No. __________ issued at _____________________ on ________________. Doc. No. __________; Page No. __________; Book No. __________; Series of 200 __.
Not for sale . May be reproduced for additional sheets
"R E S O L V E as it is hereby resolved that _________________________________________________________________, a senior executive who has been granted the power to render general management and administrative decision, be appointed as the firm's authorized sole management representative 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.
(Surname, First Name, Middle Name)
SUBSCRIBED and sworn to before me this ________ day of ______________________________________ at __________________________________________________, affiant exhibited to me his/her Community Tax Certificate. No. ____________ issued on _________________________ at ______________________________________________.
Doc. No. __________ Page No. __________ Book No. __________ Series of 200 __.
Revised 10/01/2007
THE MANAGER
Subject: Account # _______________________ Sir: Please provide the Philippine Contractors Accreditation Board (PCAB), a government agency under the Department of Trade and Industry, any information they need regarding the subject account with your bank. I am applying for a contractor's license from PCAB and part of their evaluation process is the verification of bank deposits and other assets of an applicant. This will serve as your authorization to release any information that may be requested by PCAB regarding the above subject account. Thank you. Very truly yours, ___________________________________ Signature over Printed Name __________________________________ Company Name ___________________________________ Date
Revised 10/01/2007
AUTHORIZATION
The Philippine Contractors Accreditation Board (PCAB) is hereby authorized to verify and secure information and/or copies of documents submitted by or in the name of the firm to any or all of the following agencies relative to its application filed with the PCAB: 1.Bureau of Internal Revenue 2.Securities and Exchange Commission 3.Land Registration Authority 4.Land Transportation Office 5.Social Security System
_____________________________________
By: _____________________________________ Signature over Printed Name of Proprietor or Authorized Managing Officer
Date: _________________________________
LIST OF LAND, BUILDING AND OTHER IMPROVEMENTS OWNED BY AND REGISTERED IN THE NAME OF THE COMPANY AS OF THE BALANCE SHEET DATE
TCT/CCT NUMBER
LOCATION
(St. #, Barangay, Municipality/ City, Province)
ACQUISITION COST
ACQUISITION DATE
Revised 10/01/2007
_________________________________________
Signature over Printed Name of AMO _________________________________________ Company Name _________________________________________ PCAB License No. (If applicable) ________________________________________ Date Signed
LIST OF DELIVERY AND TRANSPORTATION EQUIPMENT OWNED BY AND REGISTERED IN THE NAME OF THE COMPANY ASOF THE BALANCE SHEET DATE COMPLETE DESCRIPTION
Plate No. Chassis No. Engine No. M.V. File No. CR No.
BOOK VALUE
TOTAL
LIST OF MACHINERIES/PLANTS AND OTHER CONSTRUCTION EQUIPMENT OWNED BY THE COMPANY AS OF THE BALANCE SHEET DATE COMPLETE DESCRIPTION SERIAL NO. ACQUISITION Date P Cost BOOK VALUE
TOTAL
Please reproduce if additional sheets are needed.
Revised 10/01/2007
_________________________________________
Company Name
_________________________________________
Date Signed
CFY _________________ Type of Application: (Pls. check) New Upgrading Renewal Others, pls. Specify
__________________________
Not for sale . May be reproduced for additional sheets
Revised 10/01/2007
_______________________________________ Signature over Printed Name of AMO _______________________________________ Company Name _______________________________________ PCAB License No. (If applicable) ______________________________________ Date Signed
CFY __________________ Type of Application: (Pls. check) New Upgrading Renewal Others, pls. Specify __________________________
Not for sale . May be reproduced for additional sheets
SCHEDULE OF RECEIVABLES
To be accomplished if the applicant's receivable accounts (accounts/contracts & other receivable) exceed 20% of the total networth/equity as of the latest audited balance sheet submitted in support of its application.
TYPES
AMOUNT
AGE
NAME/ADDRESS OF DEBTOR/CLIENTS
Notes: * All receivable accounts must be substantiated by confirmation of debtors/clients Please use additional sheets if necessary
Certified Correct by: _______________________________ Printed Name and Signature of External Auditor ___________________________ Printed Name and Signature of AMO
SCHEDULE OF INVENTORIES
To be accomplished if the applicant's inventory accounts exceed 20% of the total networth/equity as of the latest audited balance sheet submitted in support of its application.
Types
Amount
Age/Date Acquired
Intended Use or
Physical Condition
Place of Storage
Certified Correct by: _______________________________ Printed Name and Signature of External Auditor ___________________________ Printed Name and Signature of AMO
* The above schedules should be certified by the firms external auditor and signed by the authorized managing officer.l Not for sale . May be reproduced for additional sheets
STE AFFIDAVIT
I,____________________________________________________________________, Filipino, of legal age,
LAST NAME FIRST NAME COMPLETE MIDDLE NAME
born on
M M / D D/ Y Y Y Y
single/married to __________________________________________and
residing at ____________________________________________________________________ having duly sworn in accordance with law depose and say: 1. That I am a duly licensed __________________________ and holder of PRC registration no. ___________ valid up to _______________ (copy of my PRC is attached at the back hereof); 2. That I hold a Bachelor's Degree in _________________________________________________________ at ______________________________________________________ given on _____________________; (NAME OF SCHOOL) 3. That my Tax Identification Number (TIN) and Social Security No. are and respectively;
4. That I am not presently employed in any government office or government owned/controlled corporation, nor a full time instructor, nor working abroad;
(NAME OF FIRM) (PROFESSION)
5. That I am employed by _________________________________________________________________ on regular and full-time basis with the position of _________________________________and presently being nominated as Sustaining Technical Employee for CFY _____________; 6. That I am not a holder of a contractor's license; 7. 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; 8. That I have not been convicted by a court of competent jurisdiction of any offense involving moral turpitude; 9. That I am fully aware that my failure to notify the PCAB of my disassociation with my present employer shall cause my disqualification to be sustaining technical employee or authorized managing officer or a license applicant with PCAB; 10. That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever sources PCAB may consider appropriate; 11. That I am executing this affidavit to attest to the truth of the foregoing. FURTHER AFFIANT SAYETH NAUGHT. _________________________________ Affiant SUBSCRIBED and sworn to before me this _____ day of ___________________, 200___ affiant exhibited his/her Community Tax Certificate No. _____________ issued at ___________________ on ______________. Doc. No. __________; Page No. __________; Book No. __________; Series of 200 _______.
Notary Public
Until December 200 ___
CFY ___________________ Type of Application: (Pls. check) New Upgrading Renewal Others, pls. specify _____________________
Revised 10/01/2007
disassociated therefrom, failure to notify the Board of his disassociation in accordance with paragraph 5 and 6 of the Affidavit of Undertaking.
6. Not a holder of a Contractors License. If you meet the above requirements, kindly accomplish this affidavit. Erasure must be properly initialled. All statements are subject to verification and any false statement or willful misrepresentation of a material fact in obtaining a license shall be grounds for disapproval of this application.
PASTE PROF. I.D. CARD VALID FOR CURRENT YEAR (Front) (xerox copy)
PASTE PROF. I.D. CARD VALID FOR CURRENT YEAR (Back) (xerox copy)
This is to certify that I have verified with PRC the abovestated professional eligibility/registration of the Sustaining Technical Employee. Affiant herein and found the same to be true and correct.
__________________________________________
From
To
That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever sources PCAB may consider appropriate; That I am executing this affidavit to attest to the truth of the foregoing. FURTHER AFFIANT SAYETH NAUGHT.
_________________________________
Affiant SUBSCRIBED and sworn to before me this _____ day of _________________, 200__ affiant exhibited his/her Community Tax Certificate No. ______________ issued at ____________________ on ____________________. Doc. No. __________; Page No. __________; Book No. __________; Series of 200 _______. CFY ___________________ Type of Application: (Pls. check)
New Upgrading Renewal Others, pls. specify
Notary Public Until December 200 ___ Company Name ____________________________ PCAB License No. __________________________
___________________________
Revised 10/01/2007
SUSTAINING TECHNICAL EMPLOYEE (STE) PERSONAL APPEARANCE FORM (To be accomplished fully by the STE)
Name: ______________________________________________ Sex: __________________ Address: ____________________________________________________________________ Profession: __________________________________ PRC Reg. :_____________ Nominating Firm: ____________________________________________________________ Contractor's License No.: ______________________
I hereby confirm the following: 1. The veracity of the information reflected on the STE Affidavit and Affidavit of Construction Experience (PCAB Form Nos. 107 & 108, copies attached) that I executed in favor of the above firm; 2. That I am fully aware that my failure to notify the PCAB of my disassociation from the above-stated nominating firm and any misrepresentation in the attached forms shall cause my disqualification as sustaining technical employee, or authorized managing officer, or a licensee applicant with PCAB per Board Resolution No. 401, Series of 2001.
3. That I have been previously connected with the following companies: Previous Employers
Date of Employment Date of Resignation
Position
1. ______________________________ Personal Appearance and Presentation of Two (2) Identification Documents attested by PCAB designated staff or DTI Regional/Provincial Staff _______________________________
Signature over Printed Name/Position
AFFIDAVIT
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 __________________________________________________________; (Name of Firm) Officer (AMO) of
2. That I appoint ____________________________, whose picture and signature appear below, to transact business with PCAB; i.e, present for pre-screening my application for contractors license or any application related thereto, file/follow-up, submit documents, receive notices/license in connection with the said application and the like.
3. That I am aware that I am responsible/liable for any or all acts/representation made by my representative in connection with the functions stated herein. 4. That I undertake to notify PCAB in the event that this appointment is modified, amended or revoked.
_______________________________________
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. _________ Series of _________ Notary Public Until December 200 ___
(Note: Please submit original and one duplicate to PCAB. Keep another copy for presentation everytime you transact with PCAB)
AFFIDAVIT
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 Authorized Managing ________________________________________; (Name of firm) Officer (AMO) of __________
2. That the abovestated firm had duly appointed ____________________________, whose picture and signature appear below, to transact business with PCAB; i.e, present for pre-screening its application for contractors license or any application related thereto, file/follow-up, submit documents, receive notices/license in connection with the said application and the like. ______________________________ (Signature over Printed Name) ______________________________ ______________________________
HOME /MAILING ADDRESS
3. That we are aware that we are responsible/liable for any or all acts/representation made by the above representative in connection with the functions stated herein. 4. That the firm undertakes to notify PCAB in the event that this appointment is modified, amended or revoked.
________________________
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. _________ Series of _________ Notary Public Until December 200 ___
(Note: Please submit original and one duplicate to PCAB. Keep another copy for presentation everytime you transact with PCAB)
Application for REGISTRATION AND CLASSIFICATION OF CONTRACTOR FOR GOVERNMENT INFRASTRUCTURE PROJECTS with the Philippine Contractors Accreditation Board In behalf of ____________________________________________________________
(Name of Firm) a contractor duly licensed with the Philippine Contractors Accreditation Board. I hereby request for registration pursuant to the implementing Rules and Regulations of PD 1594, as amended.
I hereby certify that the information and documents contained in this application are true and correct of my own personal knowledge. I am fully aware that I shall be held personally liable for any misrepresentation that may be found herein. ____________________________________
Authorized Managing Officer (Signature over Printed Name)
Republic of the Philippines} _______________________} s.s. SUBSCRIBED AND SWORN to before me this _______ day of ___________________ 200 ___ at ___________________________________ affiant exhibited to me his Community Tax Certificate No. ______________ issued at _________________________ on ________________ 200 ____. Doc. No. :
Page No. :
Book No. : Series of :
The following documents and information are hereby submitted in support of this registration application:
]
1. General Information (PCAB Form No. 602). 2. List of Single Largest Contract completed by the contractor of each Project Kind being applied for (PCAB Form No. 603). 3. Copy of Contract Agreement listed in PCAB Form No. 603 of each Project Kind being applied for duly authenticated by the tendering agency or project owner or in case of subcontract by the prime/main contractor. 4. Copy of Certificate of Acceptance/Completion from Tendering Agency/Project Owner of each Contract Agreement submitted duly authenticated by the tendering agency or project owner or in case of subcontract by the prime/main contractor. 5.Copy of Certificate of Creditable Income Tax Withheld (Form 1743.1/1743.750/2307), stamped-received by BIR for each private contracts and sub-contracts.
NOTE: Application for registration and supporting documents must be submitted in a folder and signed on each and every page by the Proprietor/Authorized Managing Officer. Do not fill, for PCAB use only: Total no. of pages submitted ________ Checklisted by: ___________________________________
(Signature over Printed Name)
_________________ (Date)
(Revised 032601_GSD)
Note: Only citizens or entities with at least 75% Filipino equity may apply
Contractors Particulars
FIRM NAME
:
TEL, NO.:
OFFICE ADDRESS:
Corporation %
Partnership %
Sole Proprietorship
Filipino:
Foreign:
License Particulars
Date Issued:
Last Renewal:
Present Category:
Upgrading
SIZE RANGE
KIND OF PROJECT
(Please check)
GENERAL ENGINEERING
GE-1 GE-2 GE-3 GE-4 GE-5 GB-1 GB-2 GB-3 GB-4 Road, Highway pavement, Railways, Airport horizontal structures, & Bridges Irrigation and Flood Control Dam, Reservoir, and Tunneling Water Supply Port, Harbor, and Offshore Engineering Building and Industrial Plant Sewerage and Sewage Treatment/Disposal Plant Water Treatment Plant and System Park, Playground, and Recreational Work
GENERAL BUILDING
SPECIALTY
__________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________
SP-1 Foundation Work SP-2 Structural Steel Work SP-3 Concrete Pre-casting and Pre-stressing SP-4 Plumbing and Sanitary Work SP-5 Electrical Work SP-6 Mechanical Work SP-7 Air-conditioning and Refrigeration Work SP-8 Elevator and Escalator Work SP-9 Fire Protection Work SP-10 Waterproofing Work SP-11 Painting Work SP-12 Well Drilling Work SP-13 Navigational Facilities SP-14 Communications Facilities
PCAB Form No. 603 TRACK RECORD FORM (Only complete form & supporting documents will be considered)
_________________________________________________________________________ __________________
Name of Firm
License No.
III. WITHHOLDING TAX (for subcontract and non-government contract) Withholding agent: ________________________________________________________ Name of the withholding agent's signatory: _____________________________________ Received and Stamped by: { BIR { BANK RDO No._______________________ Name: ________________________ Address:_______________________ Address: ______________________ _______________________________ _____________________________ Date: __________________________ Date: _________________________ INSTRUCTIONS: 1.Attach at the back of this form clear & legible copies of the following documents: a) Contract agreement duly authenticated by the tendering agency/project owner/ prime contractor in case of subcontract. b) Letter or certificate of acceptance duly authenticated by the tendering agency/ project owner/prime contractor in case of subcontract. c) Certificate of creditable income tax withheld of source (BIR Form 1743.1, 1743.750 or 2307) duly stamped-received by the BIR or Bank Collecting Agent for subcontracts & non-government or private contracts) 2.Submit only one track record for each project kind. _______________________________________________ Authorized Managing Officer/Proprietor (Signature over Printed Name)