Republic of the Philippines OFFICE OF THE PRESIDENT OPTICAL MEDIA BOARD ‘No. 35 Scout Limbaga Stree, Brgy: Laging Handa, Quezon City Zip Code 1103 Tel. Nos. 374-1393 + 374-1390 / Telefax No, 374-0237 APPLICATION FOR ACCREDITATION PLEASE TYPE/PRINT INFORMATION LEGIBLY DATE APPLIED ‘BUSINESS NAME “ROCREDITATIONNO, | APPLICANTIREPRESENTATIVE POSITION NATUREOF | BUSINESS ADDRESS ‘CONTACTO, BUSINESS | [ Sioa EMAIL ADDRESS TWPEOF ASSOCIATION TEL. NOUFAXNO. OWNERSHIP pe aa sinete ane promnerossie | pRODUCERLOCAL DQ coarorarion LICENSEE Qoarmiensar ee - EMAIL ADDRESS | ACQUIRED BUSINESS PREVIOUS OWNER OLD REG.NO. METHODOF 7 ACQUISITION ‘PREVIOUS BUSINESS NAME, ‘OLD LICENSE NO, Ou Dest PREVIOUS DUSINESS ADDRESS ‘Dare ACQTRED oe UNDERTAKING Thereby accept the authority of OMB representatives or azents to inspect our business establishments, to check compliance with R.A. 9239 and its implementing rules and regulations and to take into custody optical media dises, which, in plain view, are in violation of the law nd other materials and equipment used in the production, sale or distribution thereof. | understand that any false information made will be ground for denial of application or revocation of accreditation andéor will be subject to the penal provisions of R.A. 9239 and its implementing rules and regulations, Thereby certify to the truth and correctness ofthe above information under pain of perjury of falsification, SIGNATURE OVER PRINTED NAME OF APPLICANT SUBSCRIBED AND SWORN to before me this day of at fant having exhibited to me hslher Community Tax Certificate No. issued at on BOC NO, PAGE NO. BOOK NO, SERIES OF ‘Administering Ofer Notary Publi