Documente Academic
Documente Profesional
Documente Cultură
011
Revision 2, 01 December 2016
_______________________________
BGen CHARITO B. PLAZA (AFPR) MNSA, PhD Date
Director General
Philippine Economic Zone Authority
Madam:
Pursuant to sections 5 and 6 of Republic Act 7916, otherwise known as the Special
Economic Zone Act of 1995, as amended by RA No. 8748 and PEZA Board Resolution No. 00-
411, as amended by BR No. 11-066, I am applying for the declaration of a building with a
gross floor area of _________________________ square meters to be establish/established on a
__________________-square meter lot located at
______________________________________________________________________ as IT
Facilities Enterprise to be known as ___________________________________.
The undersigned attest that the documents/information submitted are true and are correct and
that I assume full responsibility for any misrepresentation and/or violation thereof.
1. Duly Accomplished and Notarized Application Form, Anti-Graft Certificate (R.A. 3019) and Applicant's
Undertakings
2. SEC Registration Certificate and Articles of Incorporation and By-Laws (including latest GIS)
3. Audited Financial Statements for the last three (3) years of operation, if applicable
4. Board Resolution/Special Power of Attorney/Secretary’s Certificate designating the company’s authorized
representative to PEZA
5. Project Description, which should provide, among others, development plan and schedule of the
proposed IT Facilities
6. Site development plan and vicinity map reflecting its surroundings within one (1) kilometer radius of the
project site
7. Proof of land ownership or any document confirming the applicant’s authority to use the land subject of
the proposed IT Facilities
8. Environmental Compliance Certificate issued by the Department of Environment and Natural Resources,
if applicable
9. Copy of the Building Permit, Occupancy Permit and latest Fire Safety Inspection Certificate issued by the
LGU for existing IT Facilities
10. Secretary’s Certificate of Compliance to minimum requirements for existing IT Facilities
11. Favorable endorsement from the economic zone developer/operator
President/General Manager
EDD.1.F.011
Revision 2, 01 December 2016
Date Filed
O.R. No. / Date
B. APPLICANT
Company Name
TIN No.
Company Address
Telephone No.
Fax No.
Email Address
Website
C. AUTHORIZED REPRESENTATIVE
Name
Address
Telephone No.
Fax No.
Email Address
Site of Operation
Location ____________________________________________
(Lot No. Block No. Phase No. )
2
EDD.1.F.011
Revision 2, 01 December 2016
E. PROJECT BRIEF
The Proponent
1. Name of Company
2. SEC Registration
Cert. of Registration No.
Date
Amendment (if any)
Nature
Date
3. Nature of Business
4. Incorporators
NAME NATIONALITY
5. Current Stockholders
AMOUNT OF AMOUNT OF
NO. OF
NAME NATIONALITY SUBSCRIBES PAID-UP
SHARES
SHARES SHARES
6. Principal Officers
NAME POSITION
3
EDD.1.F.011
Revision 2, 01 December 2016
4
EDD.1.F.011
Revision 2, 01 December 2016
8. Corporate Nationality
9. Affiliate Company
PhP
YEAR
NAME OF PROJECT DESCRIPTION
ESTABLISHED
The Land
1. Location
2. Land Area
3. Ownership/Right Over Land Full Ownership Lease Contract
MOA Joint Venture Agreement
Others
The Project
1. Building Gross Floor Area
2. Levels/No. of Storeys
3. Floor Area Allocation
TOTAL
Use separate sheet/s if necessary
5
EDD.1.F.011
Revision 2, 01 December 2016
Existing/Fully developed
If new development
i) date of commencement
ii) expected date of completion
If under development
i) percentage completion
ii) date started
iii) expected date of completion
If existing/fully developed
i) date established
ii) occupancy rate
iii) line of business of occupants
3. Labor Requirements
a. Power System
i) Power source
ii) Power franchisee
iii) Power transmission and distribution
iv) Back-up power generation
◘ Source
◘ Capacity
b. Telecommunication System
i) Telephone provider
ii) No. of lines
iii) Telecommunication backbone
◘ High speed voice and data communication
6
EDD.1.F.011
Revision 2, 01 December 2016
7
EDD.1.F.011
Revision 2, 01 December 2016
COMPONENT AMOUNT
Land Acquisition Cost PhP
Ecozone Development Cost
Land Preparation
Building Construction Cost
Other Costs
TOTAL PhP
Use separate sheet/s if necessary
8
EDD.1.F.011
Revision 2, 01 December 2016
9. Sources of Funds
___________________________
Affiant
9
EDD.1.F.011
Revision 2, 01 December 2016
____________________________
Designation
10
EDD.1.F.011
Revision 2, 01 December 2016
_________________________________
Notary Public
Until December 31, 20______
Doc. No.
Page No.
Book No.
Series of
11
EDD.1.F.011
Revision 2, 01 December 2016
APPLICANT'S UNDERTAKINGS
In applying for PEZA registration, the Applicant herewith makes the following representations and commitments:
1 . That the applicant is capable of operating, on a sound and efficient basis, and of contributing to the objectives of
the Philippine Economic Zone Authority in particular and to the development of the national economy in general;
5 . That the applicant shall submit periodic reports and other information, pertaining to its activities in the Ecozone
that the Authority may require;
6 . That the applicant has read Republic Act No. 7916, as amended, and the Rules and Regulations adopted by the
PEZA and commits itself to abide by the provisions thereof as well as amendments thereto;
7 . The applicant will start and operate the project covered by this application within such reasonable time as may be
fixed by the Authority;
8 . That the applicant's Board of Directors has authorized the filing of this application in accordance with the terms
thereof if the applicant is a corporation;
9 . That pursuant to Section 2(p), Rule I of the PEZA Rules, the applicant's income derived within the ecozone shall
be subject to taxes under the National Internal revenue Code pursuant to Section 25 of the Act;
10 . That no Board member or officer of the Philippine Economic Zone Authority has an investment or any other
financial interest, direct or indirect, in the applicant's enterprise; and
11 . That there exists no dummy relationship between any of the stockholders and/or principal officers of the
applicant and any foreign individuals/business entity.
Affiant
Designation
Republic of the Philippines )
City / Province of ) S.S.
Subscribed and sworn to before me this_________ day of ________________ , 20___ in the City/
Province of ______________________. Affiant exhibited to me his Resident Tax Certificate No. _____________
issued at ___________________________ on _______________, 20___
Notary Public
Until December 31, 20_____
Doc. No.
Page No.
Book No.
Series of 20
EDD.1.F.011
Revision 2, 01 December 2016
ANTI-GRAFT CERTIFICATE
That pursuant to the provisions of Section 3 and 14 of Republic Act 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 PEZA in
connection with the filing and processing of this application, nor it 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 PEZA
has an investment or other financial interest, direct or indirect, in the applicant; and
That this certificate was made with the approval of applicant's Board of Directors or
Management.
Affiant
Notary Public
Until December 31, 20_____
Doc. No.
Page No.
Book No.
Series of 20