The Provincial Director
DTI-Cebu City

           In accordance with the provisions of Section 3(c) of Act 2728 as amended by Acts Nos. 3715 and 3969, and Section 79(b) of the Revised Administrative Code and implemented by Commerce Administrative Order No. 2, Series of 1979, dated February 14, 1976, I wish to apply for renewal of my Certificate of Authority as a MERCHANDISE BROKER/SUB-AGENT.

           I hereby certify that during the past twelve (12) months I have not been convicted by a competent court for any violation of law, ordinances or regulation involving cheating, fraud, deceit, misrepresentation or wrongful conversion of property or for any crime involving moral turpitude. (If the preceding) statement is in the affirmative, a certified copy of the decision of the court should be attached thereto)

Very truly yours,                        

___________________________
(Signature of Applicant)      


___________________________
Name in Print              



___________________________
Address & Telephone No.    

Alien Cert. of Reg. # __________
Date _______________________
Last date reported to the Bureau
of Immigration _______________

REPUBLIC OF THE PHILIPPINES)
                                                 : S.S.
                                                 )

                SUBSCRIBED AND SWORN to before me this 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st day of January February March April May June July August September October November December Affiant exhibited to me his/her Residence Certificate No. __________ issued at _____________on ___________20 00 01 02 03 04 05 06 07 08 09 10

NOTARY PUBLIC                   
Until Dec. 31, 20 00 01 02 03 04 05 06 07 08 09 10          
PTR No. ___________-_______
TAN ______________________
Previous License No. ________

Doc. No. _________
Page No. _________
Book No. ________
Series of _________