SEC FORM 28.

1 – 1 – AF
Application for Payment of Annual Fees
Broker Dealer
For the Year ___________

Check all the applicable boxes:

Broker in Securities Broker in OTC Market

Dealer in Securities
Broker-Dealer in Securities
Broker in Proprietary Shares
Dealer in Propriety Shares
Broker-Dealer in Proprietary Shares
Voice Broker in Government Securities
ATS Broker Dealer in Securities
Dealer in OTC Market
Exchange Trading Participant
Non-Exchange Trading Participant
Member-Phil. Association of Securities Broker Dealers. Inc. (PASBDI)
Member-Phil. Association of Club Shares Brokers Inc. (PACSBI)
Plans to or Engages in Market Making Transactions

Name of Applicant: Certificate of Registration No.

TIN:
Applicants Principal Office Address: Tel No.
Fax No.
Email Address:
Contact Person and Designation: No. of Branch Office:

The above-named applicant hereby applies for the payment of annual fees and hereby certifies that the information
contained in its most recent filing SEC Form 28.1-1 is true, correct, current, accurate and complete.

Reviewed by:

_______________________________________
Printed Name/Signature/TIN of
Associated Person/Compliance Officer
________________________________________________________
Printed Name/Signature/TIN of Company President
________________________________________________________
Date

Subscribed and sworn to before me this ______________ day of ____________________20____ exhibited to me his/her valid identity
card: ___________________________ issued at ____________________________ on ________________.

Notary Public

Doc. No._______.
Page No._______.
Book No.______.
Series of 20____.

…………………………………………………………………………………………………………………………………………………………………

1. At least two (2) sets with cover sheet;

2. Endorsement letter (SEC FORM NELET-AF);
3. Copy of previous license or Confirmation of Payment (COP);
4. Original copy of the surety bond for firms with less than PhP100M capitalization (not applicable to broker in
proprietary shares); and
5. Payment of fee: refer to existing SEC Schedule of Fees and Charges.

Rev2016