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OR No.

_________________
REPUBLIC OF THE PHILIPPINES Amount: ________________
Department of Transportation and Communications Date: ___________________
LAND TRANSPORTATION FRANCHISING AND REGULATORY BOARD
Tiguma, Pagadian City

CHANGE OF CHASSIS
Petition and Order
OPERATOR MAIN CASE NUMBER
ADDRESS
FRANCHISE OF AUTHORITY CPC PA SP
NUMBER OF AUTHORIZED UNITS VALIDITY
AUTHORIZED ROUTE OF OPERATION
TYPE OF OWNERSHIP Single Proprietorship Cooperative
Partnership Corporation
ROUTE / AREA OF OPERATION
TYPE OF SERVICE PUJ TTS SHS
PUB TX SB RETURN PLATE
AC REGULAR TH AUVX RECEIPT

APPLICANT REQUESTS AUTHORITY TO Substitute ( ) units


Register ( ) Hereunder listed:

UNIT/S WITHDRAWN UNIT/S FOR REGISTRATION


CHASSIS CHASSIS
MAKE PLATE NO MOTOR NUMBER MAKE PLATE NO MOTOR NUMBER GW
NUMBER NUMBER

NOTE: CROSS OUT UNUSED SPACES (X)

CERTIF ICATION

It is certified that I have caused the preparation of the foregoing application, that I have read and understood the
contents of the same and all the allegation therein are true and correct to the best of my knowledge and belief.

COUNSEL OF RECORD FOR THE APPLICANT APPLICANT


TIN PTR No. TIN DATE
ADDRESS

RECOMMENDING APPROVAL: APPROVED AS PRAYED FOR:

ATTY. ABDULGAFAR A. MOHAMMAD, CESO V


ZERITA F. CLIMACO Regional Director
OIC, CTDO
Technical Evaluation Division

COPIES FURNISHED:
The Applicant, c/o
The Director, LTO Regional Office No. IX, Pagadian City
The Transportation District Officer, LTO Agency of

File
CONDITIONS

1. Applicant shall register with the Land Transportation Office (LTO)specified at the bottom of front page,
under Copies Furnished, under HIRE Denomination the new unit/s authorized herein for operation within
thirty (30) days from receipt of a Confirmation of this Order by the Agency concerned, and shall submit to this
Board a certified copy of the Certificate of Registration of the unit/s or motor/s registered within ten (10) days
from the date of such registration.

2. Applicant shall operate the units herein authorized strictly in accordance with the Terms and Conditions
prescribed by the Decision.

3. Only a copy of this Order delivered directly to LTO shall be the basis for registration of the unit/s described
therein.

4. Failure of Applicant to comply with any of the foregoing requirement will be considered sufficient cause for
this Board to withdraw the authority herein granted.

REMARKS:

This is to certify that all other pertinent data stated in the petition are CORRECT per
Records of the Board.

DATE
CHIEF
Management Information Division

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