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

APPLICATION FOR RENEWAL
MERCHANDISE BROKER or SHIP/SUB-AGENT
(Please submit one copy)

 

Date

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
day of Affiant exhibited to me his/her Residence Certificate No. __________ issued at _____________on ___________20



 

NOTARY PUBLIC                   
Until Dec. 31, 20          
PTR No. ___________-_______
TAN ______________________
Previous License No. ________

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