APPLICATION FORM FOR BIR-IMPORTER CLEARANCE CERTIFICATE (BIR-ICC)

for NON-INDIVIDUAL
To be accomplished and signed by the authorized Key Officer/Board Member as indicated in the latest
Revised Sept 2016 SEC General Information Sheet

NAME OF APPLICANT : BEROVAN MARKETING, INCORPORATED

TAXPAYER IDENTIFICATION NUMBER (TIN) : 000-310-215 E-MAIL info@berovan.com

ADDRESS :
:
PRINCIPAL PLACE/HEAD OFFICE OF BUSINESS 16 EMILIO OSMEA ST., GUADALUPE, CEBU CITY

CONTACT NUMBER : 032-230-3891; 032-230-3888

LINE OF BUSINESS : GENERAL MERCHANDISE PSIC:

NAME OF AUTHORIZED KEY OFFICER : ROSEMARIE L. WONG

POSITION/DESIGNATION : PRESIDENT TIN: 141-695-003-000

ENCLOSED ARE THE FOLLOWING SUPPORTING DOCUMENTS TO THIS APPLICATION (PLEASE CHECK):

_____ 1. CERTIFIED TRUE COPY OF LATEST MAYORS BUSINESS PERMIT

_____ 2. PROOF OF OWNERSHIP/LAWFUL OCCUPANCY OF PRINCIPAL PLACE/HEAD OFFICE OF BUSINESS (i.e., ELECTRIC,
WATER OR FIXED TELEPHONE LINE)
_____ 3. DELINQUENCY VERIFICATION CERTIFICATE ISSUED BY THE CONCERNED LARGE TAXPAYERS
SERVICE/NATIONAL/REGIONAL OFFICE WITH A VALIDITY PERIOD OF ONE (1) MONTH FROM DATE OF ISSUE
_____ 4. ORIGINAL COPY OF CERTIFICATE OF GOOD STANDING ISSUED BY THE SECURITIES & EXCHANGE
COMMISSION/COOPERATIVE DEVELOPMENT AUTHORITY/NATIONAL ELECTRIFICATION ADMINISTRATION
_____ 5. ORIGINAL COPY OF SECRETARYS CERTIFICATE CERTIFYING THAT A BOARD RESOLUTION WAS PASSED
AUTHORIZING THE KEY OFFICER/BOARD MEMBER INDICATED IN THE SEC GENERAL INFORMATION SHEET TO
SIGN THE APPLICATION FORM WITH HIS/HER SPECIMEN SIGNATURE, PICTURE & PHOTOCOPY OF VALID
GOVERNMENT-ISSUED IDENTIFICATION CARD

I HEREBY DECLARE, UNDER THE PENALTY OF PERJURY, THAT THIS APPLICATION HAS BEEN MADE IN GOOD FAITH,
AND THAT THE REPRESENTATIONS INCLUDING THE ACCOMPANYING SUPPORTING DOCUMENTS HAVE BEEN VERIFIED BY ME
AND TO THE BEST OF MY KNOWLEDGE, BELIEF, AND INFORMATION ARE CORRECT, COMPLETE AND TRUE.

ROSEMARIE L. WONG
Signature over Printed Name of Authorized Officer

SUBSCRIBED AND SWORN to before me this ______ day of JULY 2017 in Cebu City, applicant exhibiting to me his/her competent evidence
of identity (government-issued identification card) No. _________________, bearing his/her photograph and signature, issued on
______________________ by ____________________ at ____________________________________.

NOTARY PUBLIC