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 :

TAXPAYER IDENTIFICATION NUMBER (TIN) : E-MAIL

ADDRESS :
:
PRINCIPAL PLACE/HEAD OFFICE OF BUSINESS

CONTACT NUMBER :

LINE OF BUSINESS : PSIC:

NAME OF AUTHORIZED KEY OFFICER :

POSITION/DESIGNATION : TIN:

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

_____ 1. CERTIFIED TRUE COPY OF LATEST MAYOR’S 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 SECRETARY’S 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.

__________________________________________
Signature over Printed Name of Authorized Officer

SUBSCRIBED AND SWORN to before me this ______ day of ___________________ 20______ in

____________________________________, 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