PHILIPPINE ECONOMIC ZONE AUTHORITY

PEZA Building, Roxas Boulevard corner San Luis Street, Pasay City
Metro Manila, Philippines
APPLICATION FOR REGISTRATION/ACCREDITATION
AS AN ECOZONE SERVICE ENTERPRISE
(For Customs Broker, Freight Forwarder/Trucker and Security Agency)
Date Filed _____________
O. R. No. _____________
Amount _____________
Name of Firm : ________________________________________________________________
Address : _____________________________________________________________________
_____________________________________________________________________________
Telephone No. : ____________________Fax No. ________________ E-mail ______________
Applicants Representative (Contact Person) to PEZA :
Name : ______________________________________________________________________
Address : ____________________________________________________________________
Telephone No. : __________________________ Fax No. ______________________________
Applicants Existing Business Entity, Registration (if any):
Office
Date
Securities and Exchange Commission (SEC)
________________
Department of Trade and Industry
________________
Bureau of Customs (BOC)
________________
Others, please specify __________________
________________

Registration No.
_________________
_________________
_________________
_________________

Nature of Business Entity:

Division of Existing Corporation
___________________________________
Division of New Corporation as one of its Business ___________________________________
New Corporation as its Sole Business
Proposed Corporation
Partnership
Single Proprietorship
Others (Please Specify)

_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________

Issued Licenses/Permits (pls. check)

______ Mayors Permit
______ Customs Brokerage Licenses, Person and Firms , valid until _____________________
______ Copy of Franchise from LTO; Case Decision from LTFRB
______ LTO Registration Certificate/Official Receipt of vehicles approved under LTFRB
Case Decision
______ Annual Permit to Operate/Clearance from Philippine Port Authority (PPA)
______ Certificate of Accreditation from the Philippine Shippers Bureau (for Sea Freight)
______ Authority to Operate from the Civil Aeronautic Board (for Air Freight)
_______ PC/PNP Clearances : ( i) PNP Regular Permit to Operate or Temporary License to
Operate; and (ii) updated firearms licenses
______ Latest Disposition Report validate by PNP-SOSIA
______ Bond with PNP (copy only)

Project Summary:
1. Brief Description of the Project (Describe operations, services to be provided in the zone,
arrangement, etc.)

2. Brief History of Applicant

(Please attach separate sheet, if necessary)

3. Organization Chart: (Please attached separate sheet)

Write-up on the organization:

4. Financial Institutions from which the Applicant Intends to Obtain Financing:

5. Capital Structure - For Corporations Only (Value in Peso)

Common Stock
Authorized No.
___________________

_______________ Amount P ____________ Par _________

No.

Subscribed
Amt. P % Total

1. Filipino
2. Non-Filipino
a.
b.
c.
d.
e.
Total
6. Capital of Partners or Single Proprietor
Nationality
(Indicate if
Naturalized) Residence
Name

Capital

7. Business Activities Other Than Those Covered by Application

No.

% of
Firms
Total

Paid-Up
Amt. P

% Total

Tax
A/C
No.

Name
________________________
________________________
________________________
________________________

Location/Address
__________________________
__________________________
__________________________
__________________________

Product/Service
____________________
____________________
____________________
____________________

8. Applicants Incorporators (For Corporation Only)

No. of
Shares

Name

Tax
A/C No.

No. of
Shares

Name

Tax
A/C No.

9. Principal Officers
Name
_______________
_______________
_______________
_______________
_______________
_______________

Position
_______________
_______________
_______________
_______________
_______________
_______________

Nationality
(Indicate if
Naturalized)
______________
______________
______________
______________
______________
______________

Residence
_______________
_______________
_______________
_______________
_______________
_______________

Tax
A/C No.
___________
___________
___________
___________
___________
___________

(Please attach list of personnel authorized to transact with PEZA)

10. Type of Service and Service Rates:
(Please attach separate sheet if necessary)
Service

Rate

11. Attach other documents as listed in checklist or standard application requirements

THE FOLLOWING DOCUMENTS ARE TO BE ATTACHED AS AN INTEGRAL PART

OF THIS APPLICATION
1.
2.
3.

4.
5.

DTI/SEC Certificate of Registration, Articles of Incorporation and By-Laws (if already

existing)
Anti-Graft Certificate, Republic Act No. 3019 (see attached form)
Certificate of Filing of Application
Bio-data of Principal Officers
Audited Financial Statements for the last three (3) years, (for existing company)

Done in the City/Province of ________________________________________________

this ___________________ day of _______________________, _______
___________________________
Affiant
___________________________
Designation
Republic of the Philippines )
) S.S.
City/Province of
)
Subscribed and sworn to before me this ________ day of __________________, ______
in the City/Province of _______________________, Affiant exhibited to me his Community Tax
Certificate No. _________________ issued at __________________, on ___________, ______
___________________________
Notary Public
Until December 31, ___________
Doc. No. _____________
Page No. _____________
Book No. _____________
Series of _____________

APPLICANTS NOTARIZED UNDERTAKING

In applying for PEZA registration, the Applicant herewith makes the following representations
and commitments:
1. The applicant is capable of operating on a sound and efficient basis and of contributing to the
objectives of the Philippine Economic Zone Authority (PEZA) and to the development of the
national economy in general. Its project is economically, technically and financially sound.
2. Applicant proposes to engage in good faith in creating a market for its services.
3. Applicant shall submit periodic reports and other information that the Authority may require
on its activities in the Ecozone.
4. The applicant has read R. A. 7916, as amended, and the Rules and Regulations adopted by
the PEZA and commits itself to abide by the provisions thereof and amendments thereto.
5. The applicant will start and operate the project covered by this application within such
reasonable time as may be fixed by the Authority.
6. If the applicant is a corporation, the Board of Directors of applicant has authorized the filing
of this application in accordance with the terms thereof.
7. That pursuant to the provisions of Sec. 3 and Sec. 14 of R. A. 3019 (Anti-Graft Act), the
applicant-enterprise has not given or promised to give and will not give any gift to any officer
or employee of the Philippine Economic Zone Authority (PEZA) in connection with the
filing and processing of this application.
8. That based on the records of the applicant no PEZA Board members or department Director
and or employee of the PEZA has an investment or any other financial interest direct or
indirect, in the applicant enterprise.
9. That there exist no dummy relationship between the stockholders or Directors of the applicant
and any foreigner.
Done in the City/Province of ________________________________________________
this ___________________ day of _______________________, _______
___________________________
Affiant
___________________________
Designation
Subscribed and sworn to before me this ________ day of __________________, ______
in the City/Province of _______________________, Affiant exhibited to me his Community Tax
Certificate No. _________________ issued at __________________, on ___________, ______
___________________________
Notary Public
Until December 31, ___________

ANNEX

ANTI-GRAFT CERTIFICATE
I, _________________________________________, of legal age, President/General
Manager of ___________________________________________________ with postal address
at ____________________________________________________________________________
after having been duly sworn, depose and say:
That pursuant to the provisions of Section 3 and 14 of R. A. 3019 (Anti-Graft Act), the
applicant enterprise, ______________________________________________________ has not
given or promised to give, and will not give, any gift to any officers, employees of the Philippine
Economic Zone Authority (PEZA) in connection with the filing and processing of this
application, nor will give such gift to any of said officers or employees after approval of its
application.
That based on the records of the applicant, no Board Member or officer of the Philippine
Economic Zone Authority has an investment or other financial interest, direct or indirect, in the
applicant; and
That this certificate was made with the approval of applicants board of directors.
___________________________
Affiant

Subscribed and sworn to before me this ________ day of __________________, ______

in the City/Province of _______________________, Affiant exhibited to me his Community Tax
Certificate No. _________________ issued at __________________, on ___________, ______

___________________________
Notary Public
Until December 31, ___________
Doc. No. _____________
Page No. _____________
Book No. _____________
Series of _____________

ANNEX

CERTIFICATION OF FILING OF APPLICATION

I, _________________________________________, of legal age, Filipino, with address

at ____________________________________________________________________________
depose and state:
That I am the President/General Manager of ____________________________________
(the Company), a domestic corporation duly organized and existing under the laws of the
Republic of the Philippines, with principal office at ________________________________, and
I officially represent the company for purposes of filing of its application with PEZA for
authorization to provide ____________________________________________________
services to all PEZA-administered economic zones.
That the contents of the herein application filed with PEZA for registration/accreditation
as an Ecozone Service Enterprise are true and correct to the best of my knowledge.

___________________________
Affiant

Subscribed and sworn to before me this ________ day of __________________, ______

in the City/Province of _______________________, Affiant exhibited to me his Community Tax
Certificate No. _________________ issued at __________________, on ___________, ______

___________________________
Notary Public
Until December 31, ___________
Doc. No. _____________
Page No. _____________
Book No. _____________
Series of _____________