Form No.

017: with hearing-RFRO

Revised as of 2/24/2021

REPUBLIC OF THE PHILIPPINES

Department of Transportation
LAND TRANSPORTATION FRANCHISING AND REGULATORY BOARD
Regional Franchising and Regulatory Office No. ________

__________________________ - Deceased Operator CASE NO.__________________

__________________________ - New Party Applicant

Application for CPC to Operate

a _______________________
with Change Party Applicant
x------------------------------------x

APPLICATION

New Party Applicant, most respectfully request for the issuance of Certificate of a Public
Convenience (CPC) to operate a ________ and, in support thereof, states that:

1. Deceased operator is a grantee of a Certificate of Public Convenience under the above case
number, for the operation of ________________ on the route: ______________________
and vice versa which CPC is valid until _____________ with the use of ______________
unit, to wit:

PLATE /
MAKE MOTOR NO. CHASSIS NO. MODEL
COND NO.

X- Nothing Follows –X

2. Applicant is financially capable to operate a ________________ service.

3. Applicant will comply with all the requirements of this honorable board and will abide
with the existing LTFRB rules and regulations, the public service act, and other pertinent /
policies.

4. Applicant has completed the necessary documentary requirements for the Application,
copies of which are hereto attached in Annexes.

5. With the consideration and approval of this Application, public necessity and convenience
will be promoted in a suitable manner.

PRAYER

WHEREFORE, it is most respectfully prayed that (a) a Notice of Hearing be issued, (b)
this Application for issuance of Certificate of Public Convenience to Operate a __________
Service be accepted, considered and transferred under the name of the New Party Applicant for
the same authorized route with the use of the same number of unit/s for a period that this
Honorable Board may deem to be fit and proper

Other reliefs just and equitable under the premises are likewise prayed for.

_______________________________, ____________________
 ______________________________________
WAIVER
Applicant
I, ______________________________________, hereby grant authority to LTFRB, to
verify the authenticity of all documents herein submitted together with this application from both
government and private sources.

______________________________________
Applicant

VERIFICATION AND CERTIFICATION OF NON-FORUM SHOPPING

I, ___________________________________, Filipino and with business address at

____________________________________________________________, after having been
duly sworn to in accordance with law hereby depose and say that:

6. I am the applicant in the above-entitled case;

7. I have caused the preparation of the forgoing application;
8. I have read the contents thereof and the same are true to the best of my knowledge and
belief on the basis of the information and documents provided to me by the applicant;
9. To the best of my knowledge, I have not commended any other action or proceeding
involving the same issue in any other LTFRB office;
10. To the best of my knowledge, no such other application, petition or pleading is pending
therein; and
11. If I learn of the same or similar application, petition, or pleading has been filed or is
pending, I shall report of such fact within five (5) days there from to the honorable board.

______________________________________
Applicant

SUBSCRIBED AND SWORN to before me this _________________ day of

__________________ at ______________________, Affiant exhibited to me his
________________________ issued at ___________________________ on
___________________________.

Doc. No.: ___________________

Book No.: ____________________
Page No.: ____________________
Series of 2021.