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)