PHILIPPINE BUSINESS REGISTRY SOLE PROPRIETORSHIP NEW APPLICATION FORM

Checklist of Requirements AUTHORIZATION

[ ] Government Issued ID I hereby authorize M __________________________________ to file my
[ ] Registration Fee Application for business name registration with DTI.
[ ] Authorized Representative’s ID
(If applicable) Applicant’s Signature ________________________
A. REGISTRATION CHECKLIST
1. DTI Registration Type New Business Name [ ] 2. LGU Registration With Permit [ ]
(Please select one) Renewal [ ] (Mayor’s Permit) Number: ________ Date Registered: _______
Certificate Number: ___________ None [ ]
Date Registered: ___________ Remarks: _____________________
3. Core Agencies Registration SSS PhilHealth Pag-IBIG
(Please check what employer numbers you want to get) [ ] [ ] [ ]

B. PROPOSED BUSINESS NAME

4. Business Name Scope & Registration Fee Barangay City/Municipality Regional National
inclusive of P30 DST ( check one) (P230.00) (P530.00) (P1,030.00) (P2,030.00)
[ ] [ ] [ ] [ ]
5.1
5. Proposed Business Names 5.2
5.3
C. BUSINESS DETAILS
6. House/Building No. & Name 7. Street 8. Barangay 9. Town/City

10. Province 11.Region 12. Phone Number 13. Mobile Number

D. OWNER’S DETAILS
14. First Name 15. Middle Name 16. Last Name 17. Suffix (e.g. Jr, Sr,I)

18. Sex 19. Date of Birth 20. Civil Status 21. Citizenship

House/Building No. & Street Barangay

Name
22. Residence
Town/City Province Region

23. Phone Number 24.TIN 25. E-Mail Address 26. Personal SSS Number

27. Mother’s Maiden Name First Name Middle Last

(Specify N/A if no Middle)
E. PSIC
28. Business Activity Manufacturer [ ] Service [ ] Retail [ ]
(Underline Main Activity and Check all that applies) Wholesaler [ ] Importer [ ] Exporter [ ]
29. Indicate Main Product Handled/Service Offered
30. Planned No. of Employees: Male [ ] Female 31. Estimated Capitalization: PhP
[ ]
F. Please Accomplish If Without TIN
Contact Person /Accredited Tax Agent (if not the owner)
First Name Middle Name Last Name Suffix (e.g. Jr, Sr, I,, II

Phone Number /Contact Information

Personal Exemption [ ] Single/Widowed/Legally Separated (No dependent)
[ ] Single/Widowed/Legally Separated (With dependent)
[ ] Married, Indicate if husband or wife claims additional exemption
 First Name Middle Name Last Name

Spouse Taxpayer’s ID No. (TIN) Employment Status Employer’s TIN

Employer’s Name
(Please accomplish If Without TIN - continuation)
Additional Exemption (List down names of dependents)
First Name Middle Name Last Name Date of Birth Incapacitated
MM/DD/YYYY (Yes/No)

UNDERTAKING

Per Department Administrative Order (DAO) No. 10-01 as amended, I hereby declare that:
1. All information supplied in this application are true and correct to the best of my belief and knowledge;
2. Any false or misleading information supplied, or production of materially false or misleading document to support the
application shall be a ground for the appropriate criminal, civil and or administrative action against me;
3. I shall voluntarily cancel or change the registered business name upon conclusive determination that a prior registrant
and lawful user of an identical or confusingly similar BN exists. Confusingly similar BN may refer to those enumerated in
item 6 (b) hereof;
4. I am fully aware of and shall strictly comply with the provision of Act No. 3883, as amended, and its implementing rules
and regulations and other related laws and rules;
5. It is my responsibility to ensure that my proposed business name is -
a) not and will not be used for business that is illegal, offensive, scandalous, or contrary to propriety (Pop’s Jueteng
Betting Station, Boobs Massage & Spa );
b) not the same or nearly the same as an existing registered business, company, partnership, corporation, cooperative
name nor it infringes on any trademark, service mark and tradename (Anne Dok’sLechon, Jolibee, Starbax Cafe);
c) not composed purely of generic or geographic words; (The Drugstore, Bacolod’s)
d) not a name which by law or regulation cannot be appropriated (OTOP, Intelligence, State College);
e) not used to designate or distinguish, or suggestive of quality of any class of goods, articles, merchandise, or service
(Best Taho Factory, A-1 Auto Repair Shop )
f) not used by the government in its governmental functions; (NBI Private Investigation Services, DTI Trading);
g) not a name or abbreviation of a name of any nation, inter-governmental or international organization (Philippine
Manpower Pooling Agency, UNESCO Marketing, WHO Health Services); and
h) is not deceptive, misleading or which misrepresent the nature of business. (“GOLD Training Services” where nature of
business is recruitment).

_____________________________________________ ___________________________
(OWNER’S Signature over printed name) Date

ID Presented:__________________________________

For DTI Use Only Approved BN Reg Fee Rec’d by

PhP _____________
TRN/PBN Date Registered BN Certificate No. Office OR Number Date Paid

BIR Tax Identification No. SSS Employer Number PhilHealth Employer Number PAG-IBIG Employer Number

Processed thru: PBRS e-BNRS, ___________________________________________________________________________

Date/Time Received: _____________________ Date/Time Processed: ________________________ Teller__________________________