PCAB Form No.

101

APPLICATION FOR NEW CONTRACTOR'S LICENSE with the PHILIPPINE CONTRACTOR'S ACCREDITATION BOARD
The following pertinent documents and information are to be submitted in support of the license application of said firm:

Checklist for New License Application A. Legal

[ ] 1. General Information (PCAB Form Nos. 101a and 102); [ ] 1.1 For Sole Proprietorship: Certified true copy of BTRCP Certificate of Registration with the pertinent BTRCP Form No. 16; For Partnership or Corporation: Certified true copy of SEC Certificate of Registration and Articles of Partnership/Incorporation and By-Laws showing Construction as the primary purpose or one of the purposes and subsequent amendments thereto; [ ] 2. Authorized Managing Officer (AMO) Nomination: [ ] 2.1 AMO Affidavit (PCAB Form No. 103) with a passport size picture of AMO; For corporations only: Original Corporate Secretary's certificate as to the nomination of the AMO (PCAB Form No. 104); [ ] 2.2 Original NBI clearance of Filipino AMO; [ ] 2.3 If AMO is Non-Filipino (in addition to 2.1): [ ] 2.3.1 Valid Working visa [ ] 2.3.2 Alien Certificate of Registration; [ ] 2.3.3 NBI clearance if AMO has resided in the Philippines for six (6) months or longer if not, equivalent clearance from AMO's home country duly authenticated by the Philippine embassy. Note: For Corporations or Associations with foreign shareholders, the following documents must be submitted

a.

Corporate Secretarys certifications as follows:

List of stockholders showing their nationalities and shareholdings; and 2. List of Board of Directors showing their names and nationality. b. Copy of latest General Information Sheet duly filed with SEC showing the names of stockholders and directors, nationality and shareholdings

B.

[ ] 3. Financial Statements (duly audited and signed on each page by a PRC-BOA accredited external auditor) and a diskette / CD (compact disc) containing the firms Audited Balance Sheet & Income Statement in the prescribed template (PCAB Financial Statement Forms A & B downloadable from the DTI website at www.business.gov.ph together with the pertinent application forms) to be submitted with the following supporting documents, if applicable: [ ] 3.1 For old companies, copy of the Quarterly or Annual Income Tax Return certified true by the BIR, covering the income reported in the Audited Income Statement submitted for the quarter or taxable year immediately preceding the filing of application, whichever is applicable; [ ] 3.2 Original copy of Bank Certification/Bank statement of account certified by Bank Manager of cash deposits as of the Balance Sheet date; [ ] 3.2.1 Authorization to Depository Bank (PCAB Form No. 105); [ ] 3.3 List of Land and Building/s owned by the company and registered in its name (PCAB Form No. 106a); [ ] 3.3.1 Certified true copy of TCT including back page; [ ] 3.3.2 Deed of Sale or Certified True Copy of Tax Declaration of Land/Building owned by the firm. [ ] 3.4 List of Construction and/or Transportation/Delivery Vehicles/Equipment/Machineries/Plants owned by the company and registered in its name (PCAB Form No. 106b); [ ] 3.4.1 Certified true copy by the LTO of the LTO Certificate of Registration and current Official Receipt of Registration of registrable Construction and/or Transportation / Delivery Vehicles / Equipment reported; [ ] 3.4.2 Certified true copy of deed of sale or sales invoices/official receipts for non-registrable construction equipment/machineries/plants; [ ] 4. Authorization to BIR & other agencies (PCAB Form No. 105a); C. Technical [ ] 5. List of Sustaining Technical Employee/s - STE (PCAB Form No. 106c) supported by the following documents for each STE: [ ] 5.1. STE Affidavit/s (PCAB Form No. 108) with a passport size picture/s of the nominated STE/s; [ ] 5.1.1 Certified true copy by PRC of valid PRC ID of STE as licensed professional or original Certification of Good Standing from PRC; [ ] 5.1.2 Original NBI Clearance/s of newly nominated STE/s; [ ] 5.2 STE Affidavit/s of Construction Experience (PCAB Form No. 109); [ ] 5.3 Personal Appearance Form duly accomplished and signed by the STE/s appearing before the designated officer of the PCAB or the nearest DTI regional/provincial office (PCAB Form No. 110)

Financial

D.

Others: PCAB Response Form (self-addressed and with sufficient stamps affixed)

NOTE: Original Signature of AMO on each and every page of the application forms including supporting documents (except item 5.3) The Board may require the AMO interview and submission of pertinent documents/information other than the above in order to fully determine the qualifications of the applicant; AMO / Applicants for TRADE category may no longer be required to take the AMO examination. Photocopies of documents, in lieu, of certified copies are accepted provided the original copies are presented for authentication
DO NOT FILL (For PCAB use only) Total No. of Pages Submitted: _______ [ ] Self-stamped envelopes * (no. ______ ) Remarks: ____________________________________ Checklisted by: ________________________________ Signature Over Printed Name/Date

_________________________________ ___________________________________

_______________________________________

* One for each depository bank; one each for BIR, LTO, & LRA; and one for each vendor of non-registrable construction equipment reported

Applicants interested to participate in government projects should accomplish Form. No. 601 (Application for Registration and Classification of Government Projects) and file the same together with the PCAB Application Form.
Revised 01/22/07

PCAB Form No. 101a

In behalf of ____________________________________________________________, (Name of Firm) I hereby request that its application for Contractor's License be approved. I hereby certify to the completeness of the information/documents contained in this application appertaining to the category/classification the company is applying for and that they are true and correct. I am fully aware that: 1. all documents submitted in support of this application are subject to verification before PCAB action; 2. any discovered misrepresentation of information and/or manifestations of fraud on the application documents submitted by my firm applicant or its Authorized Representative/Agent/Liaison Officer shall be subjected to investigation which may result to the disapproval of my application, denial/suspension/revocation of license and blacklisting of my firm and myself as its Authorized Managing Officer; and 3. unconfirmed information/documents submitted to support my firm's qualifications will be excluded for categorization/classification purposes. 4. the evaluation of my application's qualification shall be solely based on the documents submitted at the time the application was filed/accepted by PCAB.

_______________________________ Authorized Managing Officer

(Signature over Printed Name)

Republic of the Philippines) ______________________)S.S. SUBSCRIBED AND SWORN TO before me this ________ day of ___________________ 20____ at ______________________; affiant exhibited to me his Community Tax Certificate No. _______________ issued at __________________ on _________________ 20 ___. DOC. NO. _______________; PAGE NO._______________; BOOK NO._______________;

__________________________ NOTARY PUBLIC (Until December 31, _______)

PCAB Form No. 102

GENERAL INFORMATION
A. CONTRACTORS IDENTIFICATION Name of Firm: Office Address: Tel./Fax No.:

If Provincial based, contact address in Manila, if any:

Tel./Fax No.:

Website:

E-mail Address:

Type of Organization (Please Check):. [ ] Corporation [ ] Partnership SEC/BTRCP Registration No.: SSS Employers I.D.No.: CATEGORY APPLIED FOR ______________

[ ] Sole Proprietorship

[ ] Joint Venture SEC/BTRCP Expiry Date:

Date of Registration:

Tax Identification No.:

APPLIED FOR:

Principal Classification: Other Classification/s :

CLASSIFICATION/S

B. OWNERS/STOCKHOLDERS/OFFICERS* (For Corporation, Partnership and Joint Venture) Capital Name Position Nationality Subscription

Paid-Up Capital

C. AFFILIATION WITH OTHER LICENSED CONTRACTORS Name of Affiliated Firm Nature of Affiliation

Revised 03/31/04

CERTIFIED CORRECT BY:

____________________________________ Authorized Managing Officer

(Signature over Printed Name)

PCAB Form No. 103

Passport size Picture of AMO

Republic of the Philippines ) Province of ______________ Municipality of ___________

) ) S.S.

AMO AFFIDAVIT
I, __________________________________________________________________________________________, Filipino, of legal age, born on ____________________________________________________________ single/married to ________________________________________________________________________________________________ and residing at __________________________________________________________________________ having duly sworn in accordance with law depose and say: 1. That I am the Authorized Managing Officer (AMO) of ________________________________________ empowered to render general management and administrative decisions. 2. That I possess the following educational qualifications:
NAME OF SCHOOL ADDRESS DEGREE EARNED INCLUSIVE DATES OF ENROLLMENT LAST NAME FIRST NAME COMPLETE MAIDEN NAME LAST NAME FIRST NAME COMPLETE MIDDLE NAME

3. That I possess at least two (2) years of experience in the construction industry as follows (Sec. 20, R.A. 4566):
POSITION
COMPANY/ NATURE OF BUSINESS

ADDRESS

JOB DESCRIPTION

DATES OF EMPLOYMENT

(use additional sheet if necessary)

4. That I possess knowledge of the building, safety, health , & lien laws of the Republic of the Philippines & the rudimentary administrative principles of construction contracting from my work experiences in item 3 above and from the following training/seminars (Sec. 20, RA 4566):
TRAINING/SEMINAR CONDUCTED BY ADDRESS INCLUSIVE DATES OF TRAINING

5. That I am not involved in any construction malperformance suggestive of negligence, incompetence or malpractice or any act of omission liable for disciplinary action by myself or in collaboration with any other person (Rule 4, Section 4.2) 6. That I have not been convicted by a court of competent jurisdiction of any offense involving moral turpitude (Rule 4, Section 4.2) 7. That I am fully aware that my failure to notify PCAB of my disassociation with my present employer shall cause my disqualification to be an Authorized Managing Officer, a Sustaining Technical Employee or a license applicant with PCAB (For corporations and partnerships only) 8. That I authorize the PCAB to verify and investigate any or all information in this instrument from whatever sources PCAB may consider appropriate; 9. That I certify under pain of perjury that all information on this affidavit are true and correct. FURTHER AFFIANT SAYETH NAUGHT. _________________________________ Affiant

SUBSCRIBED and sworn to before me this _____ day of _________________, 200 ___ affiant exhibited his/her Community Tax Certificate No. __________ issued at _____________________ on ________________. Doc. No. __________; Page No. __________; Book No. __________; Series of 200 __.

Notary Public Until December 200__

PCAB Form No. 104

For Corporations Only AMO NOMINATION

I ____________________________________________________, Filipino, of legal age, single/married and residing at -____________________________________________________________ do hereby certify, in my capacity as the duly elected and incumbent Board Secretary of __________________________________________________________________________, that during the regular board/partners' meeting held on ___________________ wherein a quorum was present, the following resolution was unanimously approved, to wit:
(Name of Firm)

"R E S O L V E as it is hereby resolved that _________________________________________________________________, a senior executive who has been granted the power to render general management and administrative decision, be appointed as the firm's authorized sole management representative to act on all matters concerning the requirements of the PCAB and implementation of R.A. 4566 as amended by P.D. 1746."
In WITNESS WHEREOF, I have hereunto affixed my hand this ______________ day of ___________________ 200___, in ______________________________, Philippines.
(Surname, First Name, Middle Name)

_________________________________ Board Secretary

(Signature Over Printed Name)

SUBSCRIBED and sworn to before me this ________ day of ______________________________________ at __________________________________________________, affiant exhibited to me his/her Community Tax Certificate. No. ____________ issued on _________________________ at ______________________________________________.

Doc. No. __________ Page No. __________ Book No. __________ Series of 200 __.

NOTARY PUBLIC Until December 200 ____

Revised 03/31/04

PCAB Form No. 105

THE MANAGER

_________________________________ _________________________________ _________________________________

Subject: Account # _______________________ Sir: Please provide the Philippine Contractors Accreditation Board (PCAB), a government agency under the Department of Trade and Industry, any information they need regarding the subject account with your bank. I am applying for a contractor's license from PCAB and part of their evaluation process is the verification of bank deposits and other assets of an applicant. This will serve as your authorization to release any information that may be requested by PCAB regarding the above subject account. Thank you. Very truly yours, ___________________________________ Signature over Printed Name __________________________________ Company Name ___________________________________ Date

Note: To be submitted in two (2) copies.

Revised 03/31/04

PCAB Form No. 105a

AUTHORIZATION
The Philippine Contractors Accreditation Board (PCAB) is hereby authorized to verify and secure information and/or copies of documents submitted by or in the name of the firm to any or all of the following agencies relative to its application filed with the PCAB: 1.Bureau of Internal Revenue 2.Securities and Exchange Commission 3.Land Registration Authority 4.Land Transportation Office 5.Social Security System

Name of Applicant Firm

_____________________________________

By: _____________________________________ Signature over Printed Name of Proprietor or Authorized Managing Officer

Date: _________________________________

Revised 03/31/04

PCAB Form No. 106a

LIST OF LAND, BUILDING AND OTHER IMPROVEMENTS OWNED BY AND REGISTERED IN THE NAME OF THE COMPANY AS OF THE BALANCE SHEET DATE

COMPLETE DESCRIPTION (Type of land/building and area)

TCT/CCT NUMBER

LOCATION
(St. #, Barangay, Municipality/ City, Province)

ACQUISITION COST

ACQUISITION DATE

May be reproduced if necessary

Revised 03/31/04

_________________________________________

Signature over Printed Name of AMO _________________________________________ Company Name _________________________________________ PCAB License No. (If applicable) ________________________________________ Date Signed

CFY ___________________ Type of Application: (Pls. check)

-

New Upgrading Renewal Others, pls. specify

_______________________

PCAB Form No. 106b

LIST OF DELIVERY AND TRANSPORTATION EQUIPMENT OWNED BY AND REGISTERED IN THE NAME OF THE COMPANY ASOF THE BALANCE SHEET DATE COMPLETE DESCRIPTION
Plate No. Chassis No. Engine No. M.V. File No. CR No.

ACQUISITION Date Cost P

BOOK VALUE

TOTAL

LIST OF MACHINERIES/PLANTS AND OTHER CONSTRUCTION EQUIPMENT OWNED BY THE COMPANY AS OF THE BALANCE SHEET DATE COMPLETE DESCRIPTION SERIAL NO. ACQUISITION Date P Cost BOOK VALUE

TOTAL
May be reproduced if necessary

P
Revised 03/31/04

_________________________________________

Signature over Printed Name of AMO

_________________________________________

Company Name
_________________________________________

PCAB License No. (If applicable)

________________________________________

Date Signed

CFY _________________ Type of Application: (Pls. check) New Upgrading Renewal Others, pls. Specify
__________________________

PCAB Form No. 106c

LIST OF NOMINATED SUSTAINING TECHNICAL EMPLOYEES OF THE COMPANY

PRC REGISTRATION NAME Number Date Profession Date Employed Position in the Firm

May be reproduced if necessary

Revised 03/31/04

_______________________________________ Signature over Printed Name of AMO _______________________________________ Company Name _______________________________________ PCAB License No. (If applicable) ______________________________________ Date Signed

CFY __________________ Type of Application: (Pls. check) New Upgrading Renewal Others, pls. Specify __________________________

SCHEDULE OF RECEIVABLES

PCAB Form No. 107

To be accomplished if the applicant's receivable accounts (accounts/contracts & other receivable) exceed 50% of the total networth/equity as of the latest audited balance sheet submitted in support of its application.

TYPES

AMOUNT

AGE

NAME/ADDRESS OF DEBTOR/CLIENTS

Notes: * All receivable accounts must be substantiated by confirmation of debtors/clients Please use additional sheets if necessary

SCHEDULE OF INVENTORIES
To be accomplished if the applicant's inventory accounts exceed 5% of the total networth/equity as of the latest audited balance sheet submitted in support of its application.

Types

Amount

Age/Date Acquired

Intended Use or

Purpose for Storing

Physical Condition

Place of Storage

Please use additional sheets if necessary

PCAB Form No. 108

Passport size Picture of STE

Republic of the Philippines ) Province of _____________ ) Municipality of ___________) S.S.

STE AFFIDAVIT
I,____________________________________________________________________, Filipino, of legal age,
LAST NAME FIRST NAME COMPLETE MIDDLE NAME

born on
M M / D D/ Y Y Y Y

single/married to __________________________________________and

residing at ____________________________________________________________________ having duly sworn in accordance with law depose and say: 1. That I am a duly licensed __________________________ and holder of PRC registration no. ___________ valid up to _______________ (copy of my PRC is attached at the back hereof); 2. That I hold a Bachelor's Degree in _________________________________________________________ at ______________________________________________________ given on _____________________; (NAME OF SCHOOL) 3. That my Tax Identification Number (TIN) and Social Security No. are and respectively;
4. That I am not presently employed in any government office or government owned/controlled corporation, nor a full time instructor, nor working abroad;
(NAME OF FIRM) (PROFESSION)

5. That I am employed by _________________________________________________________________ on regular and full-time basis with the position of _________________________________and presently being nominated as Sustaining Technical Employee for CFY _____________; 6. That I am not a holder of a contractor's license; 7. That I am not involved in any construction malperformance suggestive of negligence, incompetence or malpractice or any act of omission liable for disciplinary action by myself or in collaboration with any other person; 8. That I have not been convicted by a court of competent jurisdiction of any offense involving moral turpitude; 9. That I am fully aware that my failure to notify the PCAB of my disassociation with my present employer shall cause my disqualification to be sustaining technical employee or authorized managing officer or a license applicant with PCAB; 10. That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever sources PCAB may consider appropriate; 11. That I am executing this affidavit to attest to the truth of the foregoing. FURTHER AFFIANT SAYETH NAUGHT. _________________________________ Affiant SUBSCRIBED and sworn to before me this _____ day of ___________________, 200___ affiant exhibited his/her Community Tax Certificate No. _____________ issued at ___________________ on ______________. Doc. No. __________; Page No. __________; Book No. __________; Series of 200 _______.

Notary Public
Until December 200 ___

CFY ___________________ Type of Application: (Pls. check) New Upgrading Renewal Others, pls. specify _____________________
Revised 03/31/04

INSTRUCTIONS ON FILLING UP PCAB FORM NO. 108

QUALIFICATION REQUIREMENTS OF SUSTAINING TECHNICAL EMPLOYEE

1. A technology professional, such as engineer or architect, duly licensed by the Professional Regulation Commission. 2. Holder of a Professional I.D. valid for current year. 3. Possesses at least three (3) years of experience in implementation of construction to which he is to be nominated 4. A full-time employee of the nominating contractor, not associated professionally or by employment with any other party, particularly a party engaged in construction or construction-related activities 5. Have none of the following disqualifications: a) Involvement, in any capacity, in any construction malperformance of grave consequence, suggestive of his negligence, incompetence and/or malpractice; b) Involvement, by himself or in collaboration with any other person or firm, in any act or omission liable for disciplinary action of which he is or the other person or firm was found guilty by the Board; c) Conviction by a court of competent jurisdiction of any offense involving moral turpitude; and
d) If formerly a Sustaining Technical Employee or an Authorized Managing Officer of any construction firm but

disassociated therefrom, failure to notify the Board of his disassociation in accordance with paragraph 5 and 6 of the Affidavit of Undertaking.

6. Not a holder of a Contractors License. If you meet the above requirements, kindly accomplish this affidavit. Erasure must be properly initialled. All statements are subject to verification and any false statement or willful misrepresentation of a material fact in obtaining a license shall be grounds for disapproval of this application.

PASTE PROF. I.D. CARD VALID FOR CURRENT YEAR (Front) (xerox copy)

PASTE PROF. I.D. CARD VALID FOR CURRENT YEAR (Back) (xerox copy)

This is to certify that I have verified with PRC the abovestated professional eligibility/registration of the Sustaining Technical Employee. Affiant herein and found the same to be true and correct.

Signature over Printed Name of the AMO

Date: _______________________

__________________________________________

PCAB Form No. 109

Republic of the Philippines ) Province of _____________ ) Municipality of ___________) S.S.

AFFIDAVIT OF STE CONSTRUCTION EXPERIENCE

I, _________________________________, single/married, Filipino, of legal age, with postal address at ________________________________________________, having been duly sworn in accordance with law depose and say that the projects enumerated below constitute my full & complete construction experience.
NAME and COMPLETE ADDRESS of EMPLOYER/ NAME & LOCATION of PROJECTS UNDERTAKEN Work Classification (GE, GB, SP) Nature/Scope of Work Assignment (Proj. Engr.) PROJECT DURATION (mm/dd/yy)

From

To

That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever sources PCAB may consider appropriate; That I am executing this affidavit to attest to the truth of the foregoing. FURTHER AFFIANT SAYETH NAUGHT.

_________________________________
Affiant SUBSCRIBED and sworn to before me this _____ day of _________________, 200__ affiant exhibited his/her Community Tax Certificate No. ______________ issued at ____________________ on ____________________. Doc. No. __________; Page No. __________; Book No. __________; Series of 200 _______. CFY ___________________ Type of Application: (Pls. check)
New Upgrading Renewal Others, pls. specify

Notary Public Until December 200 ___ Company Name ____________________________ PCAB License No. __________________________

___________________________
Revised 03/31/04

PCAB Form No. 110

SUSTAINING TECHNICAL EMPLOYEE (STE) PERSONAL APPEARANCE FORM (To be accomplished fully by the STE)

Name: ______________________________________________ Sex: __________________ Address: ____________________________________________________________________ Profession: __________________________________ PRC Reg. :_____________ Nominating Firm: ____________________________________________________________ Contractor's License No.: ______________________
I hereby confirm the following: 1. The veracity of the information reflected on the STE Affidavit and Affidavit of Construction Experience (PCAB Form Nos. 107 & 108, copies attached) that I executed in favor of the above firm; 2. That I am fully aware that my failure to notify the PCAB of my disassociation from the above-stated nominating firm and any misrepresentation in the attached forms shall cause my disqualification as sustaining technical employee, or authorized managing officer, or a licensee applicant with PCAB per Board Resolution No. 401, Series of 2001.
3. That I have been previously connected with the following companies: Previous Employers
Date of Employment Date of Resignation

Position

4. Other Remarks: ___________________________________________________________________________ ___________________________________________________________________________ ______________________________

STE's Signature

Date Signed: _______________________ Identification Documents Presented:

PRC ID No. ____________________ valid until ______________________

1. ______________________________ Personal Appearance and Presentation of Two (2) Identification Documents attested by PCAB designated staff or DTI Regional/Provincial Staff _______________________________
Signature over Printed Name/Position

DTI Office Address: ______________________________________________ Date: ____________________________

PCAB Form 111-A (For sole proprietorship)

Republic of the Philippines) s.s. ______________________)

AFFIDAVIT
I, _______________________________, of legal age, Filipino, married/single with postal address at ____________________________________, after having been sworn to in accordance with law, hereby depose and say:
1. That I am the Proprietor/Authorized Managing __________________________________________________________; (Name of Firm) Officer (AMO) of

2. That I appoint ____________________________, whose picture and signature appear below, to transact business with PCAB; i.e, present for pre-screening my application for contractors license or any application related thereto, file/follow-up, submit documents, receive notices/license in connection with the said application and the like.

Passport size Picture of Representative __________

______________________________ (Signature over Printed Name) ______________________________ ______________________________

HOME /MAILING ADDRESS

3. That I am aware that I am responsible/liable for any or all acts/representation made by my representative in connection with the functions stated herein. 4. That I undertake to notify PCAB in the event that this appointment is modified, amended or revoked.

_______________________________________
AFFIANT

SUBSCRIBED and sworn to before me this ______ day of ____________, 20___, affiant exhibited his/her Community Tax Certificate No. _______________ issued at ___________ on ___________________.
Doc No. __________ Page No. _________ Book No. _________ Series of _________ Notary Public Until December 200 ___

(Note: Please submit original and one duplicate to PCAB. Keep another copy for presentation everytime you transact with PCAB)

PCAB Form 111-B (For corporation.,partnership,cooperative joint venture or consortium)

Republic of the Philippines) s.s. ______________________)

AFFIDAVIT

I, _______________________________, of legal age, Filipino, married/single with postal address at ____________________________________, after having been sworn to in accordance with law, hereby depose and say:
1. That I am the Authorized Managing ________________________________________; (Name of firm) Officer (AMO) of __________

2. That the abovestated firm had duly appointed ____________________________, whose picture and signature appear below, to transact business with PCAB; i.e, present for pre-screening its application for contractors license or any application related thereto, file/follow-up, submit documents, receive notices/license in connection with the said application and the like. ______________________________ (Signature over Printed Name) ______________________________ ______________________________
HOME /MAILING ADDRESS

Passport size Picture of Representative

3. That we are aware that we are responsible/liable for any or all acts/representation made by the above representative in connection with the functions stated herein. 4. That the firm undertakes to notify PCAB in the event that this appointment is modified, amended or revoked.

________________________

AFFIANT

SUBSCRIBED and sworn to before me this ______ day of ______________, 20__ affiant exhibited his/her Community Tax Certificate No. _______________ issued at ___________ on ___________________.
Doc No. __________ Page No. _________ Book No. _________ Series of _________ Notary Public Until December 200 ___

(Note: Please submit original and one duplicate to PCAB. Keep another copy for presentation everytime you transact with PCAB)