Fair Trade Enforcement Bureau

Business Licensing and Accreditation Division

APPLICATION FOR LICENSE OF SHIP AND MERCHANDISE BROKER OR SUBAGENTS
G/F, UPRC Building, 315 Sen. Gil J. Puyat Avenue, Makati City 1200 Philippines
Tel. No.: (632) 890-4892  E-mail: fteb_blad@dti.gov.ph

Date : _________________

The Director
Fair Trade Enforcement Bureau
G/F, UPRC Bldg., 315 Sen. Gil J. Puyat Ave.
Makati City, Metro Manila, 1200 Philippines
Sir:
I am respectfully applying for license pursuant to the provision of Section 3(e) of Act 2728, as
amended by Act Nos. 3715 and 3969 of the Philippine Legislature and Section 79(b) of the Revised
Administrative Code; and certify that the information and documents attached are true and correct.
Type of Application:  New  Merchandise Broker  Sub-Agent
 Renewal  Ship Broker  Sub-Agent

Name of Business:
Business Address:
(House/Building No./Building Name) (Street Name) (Barangay)

(City/Municipality) (Province) (Region) (Zip Code)

Form of Organization: Sole Proprietorship Corporation Partnership Cooperative
Name of Applicant: ____________________________________________________ Designation:___________
(Title) (First Name) (Middle Name) (Last Name) (Suffix)
Sex: Male Female Social Classification: Abled  Differently Abled  Indigenous Person
Senior Citizen Youth  Out-of-School Youth
Nationality: ____________________________ Tax Identification No.:_____________________
Asset Size: Micro (<PhP3M) Small (PhP3M-PhP15M) Medium (PhP15M–PhP100M) Large ( >PhP100M)
Total No. of Employees: ________________________ Fax Number: ___________________________
Telephone Number:_____________________________ Mobile Number: ________________________
Email Address: _______________________________________________________________________
All personal data collected herein shall be processed according to the principles and provisions of the Data
Privacy Act of 2012 (DPA), its Implementing Rules and Regulations (IRR), and National Privacy Commission
(NPC) issuances.
CERTIFICATION
I hereby certify that during the past twelve (12) months, I have not been convicted by a competent
court, nor have any pending case for violation of any law, ordinances or regulations involving cheating, fraud,
deceit, misrepresentation or wrongful conversion of property or for any crime involving moral turpitude.

______________________________________
Printed Name and Signature of Applicant
Alien Certificate of Registration No: ________________
Date issued: ____________Valid until: _____________
Last Date Reported to the Bureau of Immigration:________

Republic of the Philippines )

City/Municipality/Province of____________ )SS

Subscribed and Sworn to before me this ___day of ______________ 20___ in the City/Municipality/Province of
_______________________; affiant exhibiting to me his valid government issued ID: ______________________
No.: _________________ issued at _____________ on ______________ valid until ____________________.

Notary Public
Doc. No. _______
Page No. _______
Book No. _______
Series of 20_____ .
CPG-FTEB-BLAD-Form No.58/rev.00/08.18.20