Pratinrece Fan Sum cimAPP FOE theca Ms 8 MIO? | Pm a we Rett mend “2 HY Sessa feminrait ConteAc tons ition naan AFFIDAVIT. Ktrame of AMO, RARGSEAN Stare | ie aaa ginal eo a “epi i ; Te A apart eet atom ott” rape snes fe * Cy ‘i having teen duly authorized to fle for this PCAB License Application, hereby request Uthat application for Contractors License be appro, ‘Afice having dhily sworn to im accordance with bw heretyy depose and state that: 1 affirm the Integrity Podge inchucled in this Affidavit, 2 WL eertfy that the husiness name and/or Secures and Rachonge Commission (SEC) reystrtion of the ‘Construction firm is valid and existing, with the changes in the Ouners/Stockholders/Directors/Officers and their ‘shareholdings as shown in the attached updated General Information Sheet (GIS). 3 Ueertity to the truthfulness and authentiity ofall information documents encnded in the financial documentary ‘equirements I have accomplished and the documents thereto attached are true and correct. 4 Leertfy furthermore tha the Social Security System ($88), Pag-IBIG, and Philltealth contributions were remitted favur of the employees of this fim. 5 PCAB is hereby authorized 1s verify and secure information and/or copies of documents submitted by or im the of the construction firm 10 ‘of the following, agencies relative to its application for PCAB License Spplcatin ied withthe PCAB. = ome 2 and Exchange Commission (SEC) irene ier Revenue GR) fo documents exbented fr TN Numer SUC= LAY = UD (This serves cs a waiver an the confidentiality provision of Section 270 of the National Internal Revenue Code af 1997 (Memorandum Cireular No. 28, 5 2006 dated May 08, 2006, and your authorization to release any information that may be requested by PCAB) Sebdbentytregag - fe oraeae TO eee e000) Pagrutulungan ss Kinibukasan haw, Bagh, Indarya at Gabyormo {Pag tm1G) —% OVO SCO! ee ee ee ‘o1nbece OLE “hineeshcnoe . eacate [ovte paeenen ak p aus. uiniate Sea peente_p. want (outs) AZ laler % anal eg ea 0 aa Ale OVinjay ae! Bas oe RRS ee ieee h ta Rin ato Ca er hfllvig TET Ne. . 2 i, amd’ spartapion Office (1.10) for the following vehicles with OR and CR Nos. "inf £ gulp R a Local Government Units (HGUs) L Other Government Agencies5 Rion Ne 0. OLA ™ This firm's ii SS Fomnnor arom heat — : ame of Ban ; comaall - Account Rear 2 Name of fan: : at Namecrt ieee Rank cette: | SABE “re oI (This serves os @ wei ‘© wale on the son/ldenitathy provision af the Sank Secrecy Lave andl benteesten lean ry bem Pt Raph neo PE rte ee ce a ‘his rs ietnjpaject oye ae lot in i staerent of work accomplhed/on gag herby certify othe trthf Lic Ines and authenticity of all information/documents encoded in the PCAB ONLINE. Sretrur ong PORTAL And contents applicant onendon meanest etnbed and ore 7 am fly aretha a Imistepresentation of information encoded ot atached as a document and/or rec Lapree eerinetinn Seamed by wy rm spent ot thoriaed Representative/Agenisizon Oflcer ibjected fo Investigation which Sel rl cy pe ty em ne td dod eatin, desil/suspenaton/revocation of license a ae dela y of i blacklisting of my Unconfirmed information/decuments submitted to support my firm's qualifications shall be ‘excluded for categorization/classification purpose; and © Theevaluation of my firm's qualications shal be clely based on the documents submitted atthe ‘time the application was [by PCAB. ‘GT further certify that 1 prepared this document, filly understood every word oft and its meaning, and have affixed ty signature hereunder soluntary sod ew heal nd cn nulcdge othe meng und oe of this document as wellasof my rights under existing wa, 'AFFIANT FURTHER SAYETH NAUGHT, Republic of the Philippines ) Province of. City/Municipality of —__ 8.8 SUBSCRIBED AND SWORN tobefore me this dayof__ JANI D2, ‘ ian eed wo me sie Geren ed on. PMR. 277540 ee so ih ete "eraserene vn SCRA i PCAR INTEGRITY PLEDGE We believe that the construction indust ty Is one of the mast susceptible to all forms of corruption that hampers the noble objectives towards national progress an its petieryneni 2e,fontrunners of nation-building, we aekowisdge tole and responsibility in ensuring that we earry out our tasks guided by ethical standards and equipped an decay, capability Sor Ue succensfel pressor {a view thereof, we pledge the following: We will present only true qualifications to PCAB so that we bbe evaluated properly and be given the csteRory and classification where we should rightfally belong, Liew uphold the dignity ofthe license and! not be instruments for unlicensed contractors to undertake construction, Uhrough license lending ner through false joint ventures/consortium or pecuda ‘combinations which is inimical tothe publi safety/interest; * We will bot employ unlicensed sub-contractors/specialty contractors which is a clear circumvention of the requirement tha al eontencee on oot — * We absolutely shun away from any form of collusion that destroys the very essence and integrity of We will not engage in bribery or do any act which constitutes graft or corrupt practice which is the root eause of bloated contract amounts; . We will not use sub-standard materials which will in any way compromise the safety, reliability and performance of the built environment; + We will not abandon our contracts and we will implement our projects faithfully in accordance with the ‘Specifications thereof; * We will provide the nevessary resources, financial and technical capability in carrying aut our contractual obligations and a far as posible, within the stipulated ime of ;omplet » Wearea re that we will be imposed diseiplir actipn should we violate any of the jitments hereof or IRePCAB Chdecf Bhs or be faa tobec ety eee " comm presse Tien} ‘Authorized Manhging Officer (AMO) (Signature and date over Printed Name) BHT congreuc toy ‘Name of Company| Republic of the Philippines PHILIPPINE HEALTH INSURANCE CORPORATION | CCirystate Center Building, 709 Shaw Boulevard, Oranbo, Pasig Ciry——, Republic of the Philippines ge PROFESSIONAL REGULATION COMMISSION SBS i PROFESSIONAL IDENTFR SS ON CARD ay LAST NAME > BAL TAZAR | FIRST NAME > VAN DAMNE | MIDDLE NAME > DIVINA REGISTRATIONNO. )> 0146240 | REGISTRATION DATE B 11/22/2016 | VALID UNTIL > 08/15/2025 CIVIL ENGINEER TRA eel CB camscannerHap-PFF.202 (v08, 0272024) FOR P19 1910 Feed USE OMY ita EPL OER IO mUWaER 210285180001 EMPLOYER'S DATA FORM (EDF) (AREA COGL HLEPHOE ROME leusoeessyourecT Lume) (ove) 254 Roost Jconsrmucnow THEREDY Coney Tat Wie NPGRMATICN GIVEN ANO AL STATENMET TSWAOE HEREANARE THUEANIDGORREST = ieee aaa Sa ‘rar et Pred ume) TELM EYRopubtcof te Phigrnes 2 0 2 2 SOCIAL SECURITY SYSTEM N SEPTEMBER CERTIFICATE OF REGISTRATION This is to certify that BHJ CONSTRUCTION L1, B3 JOHNSTON, BALIWASAN TABUK SAN JOSE GUSU, ZAMBOANGA CITY, ZAMBOANGA DEL SUR 7000 has been duly registered with the Social Security System (SSS) as employer on 29 September 2022 with Employer Number 80-0268915-9-000. Pursuant to the Social Security Law, the employer has the responsibility ta report all its employees to the SSS for coverage, deduct from their monthly salaries their respective shares of the SS contributions and, with the corresponding employers share, remit the same to the SSS. It also has the responsibility to deduct from the salaries of its employees, their monthly foan amortization, if any, and remit them to the SSS. This certification is issued this 29" day of September, 2022. MIC! - REGINO President and CEO 2o22092—. 1926474Republic of the Philippines Department of Justice National prea of Investigation sf | t rw enieresrtpereurtuananne tars aetes nf wcedineroeh ante ty lnped we be moore shismunet f°) Jesokenasglnsz baie? J Febeuary 27,2024 > 7 Tamaya vag tas, JANANE BURQUEABA WaILIBANL ASTORIAS STREET JOLO SULU ‘aren une November 09, 1994 ‘erm FILIPINO, MULTI-PURPOSE. CLEARANCE. ATION ATION, AOS RRSP RACE OF otmao PASCUAL 87 BARANGAY WALABIM SAK JOBE cerry ieyn ROU