EDD.1.F.

014
Revision 2, 01 December 2016

APPLICATION FOR PERMIT TO LOCATE

_____________________________
Date
BGen CHARITO B. PLAZA (AFPR) MNSA, PhD

Director General
Philippine Economic Zone Authority

Madam:

In accordance with PEZA Board Resolution No. 09-370 dated 21 July 2009, I am
applying for a permit to locate at ____________________________
_________________________________________________________________ for the
establishment/operation/maintenance of __________________________________.

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.

Attached hereto are:

1. Duly Accomplished and Notarized Application Form

2. Anti-Graft Certificate (R.A. 3019) and Proof of payment of Application Fee
3. DTI Registration or SEC Registration Certificate and Articles of Incorporation and By-
Laws (including latest GIS)
4. Any document confirming the applicant’s authority to use the land and/or building
5. Endorsement from the Zone Administrator for public economic zones
6. Endorsement from the registered developer/operator for private economic zones

Very truly yours,

President/General Manager
EDD.1.F.014
Revision 2, 01 December 2016

Republic of the Philippines

PHILIPPINE ECONOMIC ZONE AUTHORITY
Building 5, DOE-PNOC Complex, Energy Drive, 34th Street, Bonifacio Global City, Taguig City
Trunk Line No. 551-3451 Loc. 213 & 214 / TeleFax No. 551-3440/E-mail Add: edd@peza.gov.ph

APPLICATION FOR PERMIT TO LOCATE

Date Filed
O.R. No. / Date

A. APPLICANT
Company Name
TIN No.
Company Address
Telephone No.
Fax No.
Email Address
Website

B. AUTHORIZED REPRESENTATIVE
Name
Address
Telephone No.
Fax No.
Email Address

C. TYPE OF APPLICATION (Please Check)

New
Expansion/Additional Project

Site of Operation
Lot Area Building Gross Floor Area

Location
(Lot No. Block No. Phase No. )

Name of Ecozone

D. PROPOSED ACTIVITY/IES

Use separate sheet/s if necessary

2
EDD.1.F.014
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

Use separate sheet/s if necessary

5. Current Stockholders

AMOUNT OF
NO. OF AMOUNT OF
NAME NATIONALITY PAID-UP
SHARES SUBSCRIBES SHARES
SHARES

Use separate sheet/s if necessary

6. Principal Officers

NAME POSITION

Use separate sheet/s if necessary

3
EDD.1.F.014
Revision 2, 01 December 2016

7. Capital Structure a. Authorized PhP

b. Subscribed PhP
c. Paid-Up PhP

8. Corporate Nationality

9. Affiliate Company

NAME OF COMPANY CAPITALIZATION

PhP

Use separate sheet/s if necessary

10. Other Project Involvements

YEAR
NAME OF PROJECT DESCRIPTION
ESTABLISHED

Use separate sheet/s if necessary

The Project

1. Estimated Project Cost Breakdown

COMPONENT AMOUNT
Land Acquisition Cost PhP
Land Preparation
Building Construction Cost
Other costs

TOTAL PhP
Use separate sheet/s if necessary

1.a. Land Development Cost per sq.m.

1.b. Vertical Development Cost per sq.m.

2. Sources of Funds

SOURCE PERCENT SHARE

4
EDD.1.F.014
Revision 2, 01 December 2016

Use separate sheet/s if necessary

3. Labor Requirements

Done in the City/Province of ____________________________________________________________

this day of 20

___________________________
Affiant
____________________________
Designation

Republic of the Philippines )

) S.S
Municipality/City/Province of

Subscribed and sworn to before me this day of 20

in the Municipality/City/Province of

Affiant exhibit to me his Residence Tax Certificate No

issued at on 20

_________________________________
Notary Public
Until December 31, 20______

Doc. No.
Page No.
Book No.
Series of

5
EDD.1.F.014
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;
2 . That the project is economically, technically and financially sound;
3 . That the applicant proposes to engage, in good faith, in the creation of a market for its project/product;
4 . That the applicant has installed/undertakes to install an accounting system adequate to identify the
investments, revenues, costs and profits or losses of the project covered by this application separately from
the aggregate investments, revenues, costs and profits or losses of the other business activities of the
applicant not registered under Republic Act No. 7916, as amended by Republic Act 8748 or has
established/undertakes to establish a separate entity for the project/activities covered by this application if so
required by the Authority. (Applicable only if applicant is engaged or proposes to engage in undertaking or
activities in addition to the project covered by this application);
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.

Done in the City/Province of

this day of , 20 .

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.014
Revision 2, 01 December 2016

ANTI-GRAFT CERTIFICATE

I, ___________________________________________, of legal age, President/General

Manager/Sole Proprietor of __________________________________________________ with postal
address at _________________________________________________________ after having been
duly sworn, depose and say:

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

Subscribed and sworn to before me this__________ day of _____________, 20 _____ in

the City/Province of ________________. Affiant exhibited to me his Residence Tax Certificate No.

_____________________ issued at _______________________ on _________________________.

Notary Public
Until December 31, 20_____

Doc. No.
Page No.
Book No.
Series of 20