DB - FORM 1 : DTI - ASSISTED MSMEs - PROFILE dt tain Business Titranch mall Address — BUSINESS NAME Date of birth ae of Owner ee (rom/aahn) Gender 1 Abed male CD remate]} 5 iidgenocs renee We: Bang Bieet Barangay inancipaly Province Region District Tin tode ‘CONTACT DETAILS: Mobile Number Landtine Number Fax Number (mobile provider) (mobile number) (area code) (andine number) {area code) tandtine number) Form of Ownership (Sole Proprietorsig Partnership Corporation Cooperative Association . Foundation O)Rural Workers Organization/Association a ‘Major Business Activity (select only one) | [Manufacturing Processing) Agr. Production C] Wholesaling Retail consol Clsub-centracing Cloistrbutorsnp _ ELesporing Dlimoring”” _Elsemee Provider "1 Comoiton PRODUCT / SERVICE LINES. INITIAL CAPITALIZATION Year Established : [below P100,000 — [4>100,000to P500,000 _] >S00,000to PI.SM. (>P2.5M to pam O>P3m to Psm C>P5M to 10M >P10m to P15M >Pism to P100m Asset Size Classification, as of (pls. indicate year) [below P100,000 [4 >P100,000to P500,000 —_) > 00,000 to P1.SM [0>P1.5M to pam O>pamto sm O>PsM to Pio O>piom to pism C>Pism to P100m No. of Employees, as of. (pls. indicate year) FULL-TIME ABLE —_DIFFERENTLY-ABLED INDIGENOUS FULL-TIME ABLED —_DIFFERENTLY-ABLED INDIGENOUS (Pwo) PERSON {Pwo) PERSON Male Male Female Female yor we “Signature TO BE ACCOMPLISHED BY DTI ‘TRANSACTION REFERENCE NO. INDUSTRY CLUSTER : REGISTERED BUSINESS NAME : BUSINESS NAME REGISTERED NO. Psic: BUSINESS PERMIT (LGU) REGISTRATION NO. DATE REGISTERED (mmiddiyy)