Republic of
the Philippines
DEPARTMENT OF TRADE AND INDUSTRY
Cebu Provincial Office 3/F LDM Building, Legaspi Street, Cebu City
Phone: (6332) 2557084, 2557086 Fax: (6332) 2557609
NEW APPLICATION
FOR
MERCHANDISE BROKER or SHIP/SUB-AGENT (Please submit one copy)
Date
Sir:
In
accordance with the provisions of Section 79(b) of the Revised
Administrative Code and Sec.3(e) of Act 2728, as amended by
Acts Nos. 3715 and 3969 of the Philippine Legislature and
Commerce Administrative Order No. 2 and 3, I have the honor
to apply for a Certificate of Authority as
_______________________________________
MERCHANDISE;
SHIP; EXCHANGE; SUB-AGENT
For
the purpose, I hereby submit the following information
1.
Name of Applicant
:
2.
Business Address
:
3.
Nationality
:
4.
Civil Status
:
5.
Age
:
6.
Capital
:
7. Telephone
No.
:
8.
Bank Reference
:
9.
If Alien, State ACR No.
:
10.
Date Issued
:
11. Have you ever been convicted for any violation of law,
ordinace or regulation involving cheating, fraud, deceit or
wrongful conversion of property, of any crime involving moral
turpitude?
(If in the affirmative, attached a certified copy of the court
proceedings).
12. State the name and address of the President
or Manager (if the applicant is a partnership or corporation)
13. Name and Address of the other Offices duly authorized
to sign and in behalf of the partnership or corporation
14. Experience(state fully)
15. Describe briefly how you conduct business
16. Do you handle funds and/or merchandise belonging
to the public?
17. If the applicant is new, the following clearances
must be submitted together with the application:
1.Police
Clearance
2.Fiscal
of Justice of the Peace
3.Clerk
of Court (CFI) of the locality where applicant is presently
residing or doing business.
I
hereby declare under oath that the foregoing facts and statement
are true and correct to the best of my knowledge and belief
and the same have been given voluntarily without fraudulent
or deceitful purpose whatsoever.
IN
WITNESS WHEREOF, I have hereunto affixed my signature
this
day of
20
at ______________________________, Philippines.
SUBSCRIBED
AND SWORN to before me this
day of
, 20
.Affiant exhibited to me his/her Residence Certificate No.
__________ issued on _____________ 20
at _____________________
_______________________ NOTARY
PUBLIC
Until Dec. 31, 20
TAN ______________________
Doc.
No. _________
Page No. _________
Book No. ________
Series of _________