ERD.4.F.

003
Rev.01, Jan. 01, 2018
Republic of the Philippines
PHILIPPINE ECONOMIC ZONE AUTHORITY
DOE-PNOC Complex, Energy Center,
34th Street, Bonifacio Global City, Taguig City, Metro,Manila
Tel. No. 551-3451 loc. 231 Website: www.peza.gov.ph email: sru@peza.gov.ph

APPLICATION FOR REGISTRATION/ACCREDITATION

AS AN ECOZONE SERVICE ENTERPRISE
(For Customs Broker, Freight Forwarder, Trucker/Hauler and Security Services)

Customs Brokerage ( ) Application No.: ___________

Freight Forwarding ( ) Date Filed : ___________
Trucking / Hauling ( ) Official Receipt No. __________
Security Agency ( ) Amount Paid : ___________

Name of Firm: _______________________________________________________________

Address: _______________________________________________________________
_______________________________________________________________
Telephone No. ______________ Fax No. _____________ E-mail_______________________

Applicant’s Representative to PEZA (Contact Person):

Name: _______________________________________________________________
Address : _______________________________________________________________
Telephone No. ______________Fax No. ______________E-mail _______________________

Applicant’s Existing Business Registration with:

Office Date Registration No.
Securities and Exchange Commission (SEC) ________________ ________________
Department of Trade and Industry (DTI) ________________ ________________
Bureau of Customs (BOC) ________________ ________________
Social Security System(SSS) ________________ ________________
Bureau of Internal Revenue (BIR) ________________ ________________
Dept. of Labor & Employment (DOLE) – NLRC ________________ ________________
Cooperative Development Authority (CDA) ________________ ________________
Others, please specify_________________ ________________ ________________

Nature of Business Entity:

Single Proprietorship ( ) __________________________________
Partnership ( ) __________________________________
Corporation ( ) __________________________________
Cooperative ( ) __________________________________
Others (Please Specify) ( ) __________________________________
Issued Licenses/Permits (pls. check)
______ Mayor’s Business Permit No. _________________ valid until ___________________
______ Customs Brokerage Licenses. Person and Firms, valid until_____________________
______ LTFRB Certificate of Public Convenience (CPC) valid until ______________________
______ LTO Certificate of Registration (CR) and Official Receipt (OR) of vehicles with CPC
______ Annual Permit to Operate (PTO) from the Philippine Port Authority (PPA)
______ Certificate of Accreditation from the Philippine Shippers Bureau (for Sea Freight)
______ Authority to Operate from the Civil Aeronautic Board (for Air Freight)
______ PNP Regular / Temporary Permit to Operate valid until _______________________
______ firearms Licenses valid until
______ Latest Disposition Report validated by PNP-SAGSD dated __________________

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Project Summary:
1. Brief Description of the Project (Describe Operations, services to be provided in the Zone,
arrangement, etc.)

2. Brief Business History of Applicant

(Please attach separate sheet, if necessary)

3. Organization Chart: (please attach separate sheet)

Write – up on the Organization:

4. Financial Institutions from which the Applicant Intends to Obtain Financing:

Bank References:

5. Capital Structure- For Corporations Only (Value in Peso)

Common Stock Authorized No. Amount (PhP) Par

_____________ _____________ _____________ _____________

Subscribed Paid-Up
No. Value % to Total No. Value % to Total
1. Filipino
a.
b.
c.
d.
e.
2. Non-Filipino

Total

6. Capital of Partnership or Single Proprietor

Nationality % to Tax
(Indicate if Firm’s A/C
Name Naturalized) Address Capital Total No.

7. Business Activities Other Than Those Covered by Application

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 Name of Company
______________________
______________________
______________________
______________________
Location/Address
________________________
________________________
________________________
________________________
Product/Service
__________________
__________________
__________________
__________________

8. Applicant’s Incorporators (For Corporation Only)

No. of Tax No. of Tax

Name Shares A/C No. Name Shares A/C No.

9. Principal Officers
Nationality
(Indicate if Tax
Name Position Naturalized) Address A/C No.
_______________ ______________ _____________ _______________ _________
_______________ ______________ _____________ _______________ _________
_______________ ______________ _____________ _______________ _________
_______________ ______________ _____________ _______________ _________
_______________ ______________ _____________ _______________ ________
_______________ ______________ _____________ _______________ _________

(Please attach list of personnel authorized to transact with PEZA)

10. Type of Service and Service Rates:

(Please attach separate sheet if necessary)

Service Rate

11. Attach other documents as listed in checklist or standard application

requirements

THE FOLLOWING DOCUMENTS ARE TO BE ATTACHED AS AN INTEGRAL

PART OF THIS APPLICATION

3
 1. DTI/SEC Certificate of Registration, Articles of Incorporation and By-Laws (if existing)
2. Anti-Graft Certificate, Republic Act No. 3019 (see attached)
3. Certificate of Official Filing of Application
4. Bio-data of Principal Officers
5. Current Audited Financial Statements

Done in the City/Province of_______________________________________ this _______

day of _________________________________, __________ .

____________________
Affiant

___________________
Designation

Republic of the Philippines)

)S.S.
City/Province )

SUBSCRIBED AND SWORN to before me this ___ day of _________________,

_____
in the City/Province of __________________________, Affiant exhibited to me his
Community Tax Certificate No. ____________ issued at
_____________________________________ on _______________________ ,
____________ .

________________________
Notary Public
Until December 31,_______

Doc. No _____________
Page No._____________
Book No. ____________
Series of_____________

APPLICANT’S NOTARIZED UNDERTAKING

4
In applying for PEZA registration/accreditation, the applicant herewith makes the following
representations and commitments:

1. The applicant is capable of operating on a sound and efficient basis and of

contributing to the objectives of the Philippine Economic Zone Authority (PEZA) and
to the development of the national economy in general. Its project is economically,
and financially sound.

2. Applicant proposes to engage in good faith in creating a market for its services.

3. Applicant shall submit periodic reports and other information that the Authority may
require on its activities in the Ecozone.

4. The applicant has read R.A. 7916, as amended, and the Rules and Regulation
adopted by the PEZA and commits itself to abide by the provisions thereof and
amendments thereto.

5. The applicant will start and operate the project covered by this application within such
reasonable times as may be fixed by the Authority.

6. If the applicant is a corporation, the Board of Directors of applicant has authorized

the filling of this application in accordance with the terms thereof.

7. That pursuant to the provision of Sec. 3 and Sec. 14 of R. A. 3019 (Anti-Graft Act),
the applicant-enterprise has not given or promised to give and will not give any gift to
any officer or employee of the Philippine Economic Zone Authority (PEZA) in
connection with the filling and processing of this application.

8. That based on the records of the applicant no PEZA Board members or department
Directors and or employee of the PEZA has an investment of any other financial
interest, direct or indirect, in the applicant enterprise.

9. That there exists no dummy relationship between the stockholders or Directors of the
applicant and any foreigner.

Done in the City/Province of _____________________________________ this ________

day of _________________________________, __________ .

_______________________
Affiant
_______________________
Designation

SUBSCRIBED AND SWORN to before me this ___ day of _______________, _____

In the City/Province of _________________________, Affiant exhibited to me his
Community Tax Certificate No.__________ issued at
_________________________________, on ___________________________, _______.

____________________________
Notary Public
Until December 31,____________

ANNEX A

5
 ANTI-GRAFT CERTIFICATE

I, ________________________________________, of legal age, President/General

Manager of ________________________________________________ with postal address
at _______________________________________________________________________
after having been duly sworn, dispose and say:

That pursuant to the provisions of Section 3 and 14 of R.A. 3019 (Anti-Graft and
Corrupt Practices Act), the applicant enterprise, __________________________________
has not given or promised to give, and will not give, any gift in cash or in kind or any benefit
to any officers, employees of the Philippine Economic Zone Authority (PEZA) in connection
with the filing and processing of the application, nor will give such gift or benefit to any of
said officers or employees after approval of its application.

That based on the records of the applicant, no Board Member or officer of the
Philippine Economic Zone Authority has an investment or other financial interest, direct or
indirect, in the business of the applicant; and

That this Certificate was made with the approval of applicant’s Board of Directors.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ______________, ___

In the City/Province of ___________________________, Affiant exhibited to me Community
Tax Certificate No. _________________ issued at ______________________________ on
_________________________, __________.

______________________
Notary Public
Until December 31, ______

Doc. No. _____________

Page No. _____________
Book No. _____________
Series of______________

ANNEX B

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 CERTIFICATE OF OFFICIAL FILING OF APPLICATION

I, ______________________________________________, of legal age, Filipino, with

address at _______________________________________________________________
depose and state:

That I am the President/General Manager of ________________________________

(the “Company”), a domestic corporation duly organized and existing under the laws of the
Republic of the Philippines, with principal office at _________________________________,
and I officially represent the company for purposes of filing of its application with PEZA for
authorization to provide _______________________________________________ services
to all PEZA-administered economic zones.

That the contents of the herein application filed with PEZA for registration/accreditation
as an Ecozone Services Enterprise are true and correct to the best of my knowledge.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ____________, ______

in the City/Province of _____________________________, Affiant exhibited to me
Community Tax Certificate No. ____________ issued at __________________________ on
________________________, __________.

______________________
Notary Public
Until December 31, ______

Doc. No. _____________

Page No. _____________
Book No. _____________
Series of______________