BOI FORM N-501

APPLICATION NO.: _________________ DATE ACCEPTED : _________________

REPUBLIC OF THE PHILIPPINES BOARD OF INVESTMENTS

APPLICATION FOR REGISTRATION (Hospital) UNDER BOOK I OF THE OMNIBUS INVESTMENTS CODE OF 1987, AS AMENDED (EXECUTIVE ORDER NO. 226)

I. PROPONENT
NAME OF ENTITY NAME OF PROJECT IPP CATEGORY LOCAL FOREIGN OWNERSHIP RATIO : ________________________________________________________________ : ________________________________________________________________ : ____ Regular List ____ Mandatory List ____ Export Activities

SEC/REGISTRATION NO./DATE : ______________________________________________________________

: ___ % Filipino

___ % Foreign __________________ (Nationality)

II. CONTACT DETAILS

AUTHORIZED REPRESENTATIVE TO BOI/POSITION : ________________________________________________________________ (attached Board Resolution Appointment) EMAIL ADDRESS : ________________________________________________________________ FAX NUMBER: ________________ LANDLINE/CELLPHONE NUMBER : __________________________

OFFICE ADDRESS : ___________________________________________________________________________ PLANT/FARM/SITE ADDRESS : ________________________________________________________________

III. PROJECT PROFILE

PROJECT COST (Refer to Schedule 1):

PROJECT DESCRIPTION TYPE OF PROJECT :

New: ______ Start of Commercial Operation: __________ Capacity: __________ STATUS: _____________

Expansion: _________ % increase in capacity: __________

Modernization: _______

Existing: __________

Pioneer

_____________

Non-Pioneer

CONTRIBUTION TO THE ECONOMY Schedule 1: Project Cost (PhP) Year 0 Land Cost Cost of Licenses/ Permit from the Govt. Site Construction Cost Cost of Capital Equipment, Furniture and Fixtures Hiring and Training Cost Working Capital TOTAL PROJECT COST

Year 1

Year 2

Year 3

Year 4

Total

Schedule 2: Net Value Added [(Cost of Services- Cost of Purchases)/Cost of Services] Year Particulars 1 2 3 4 5 Total Cost of Services* (PhP000) Total Cost of Purchases** (PhP000) Net value added
* Cost of Sales (plus Operating Expenses if Supplies and Utilities are part of opex) ** Includes Food and Beverage, Supplies and Utilities costs.

Schedule 3: Job Generation Number Employed Pre-Op Employees paid on monthly basis Workers paid on a daily basis Full-time workers paid by contractors Others (Managers and Supervisors TOTAL Annual Payroll (PhP000) Employees paid on bimonthly basis Workers paid on a daily basis Full-time workers paid by contractors Others (Managers and Supervisors TOTAL Pre-Op Yr1 Yr2 Yr3 Yr4 Yr5 Yr1 Yr2 Yr3 Yr4 Yr5

Schedule 4: Timetable of the Project Activity Raw land Cost Licenses/ Permit from the Govt. Site Construction Acquisition and installation of equipment, furniture and fixtures Hiring and training employees Start of Commercial Operation Schedule (Month/Year) Related Expenses Land Cost Pre-operating expenses Civil works Capital Equipment, Furniture and Fixture Cost Training Cost Working Capital Cost (PhP000)

Schedule 5: Project Financing (total should equal to project cost) Amount (PhP '000) Equity Bank Loan Others (specify) Total Schedule 6: Status of Licensing, Permits, Consents Licenses / Permits (indicate applicable only) SEC Registration License to Operate issued by DOH Philhealth Accreditation Others (specify) Schedule 7: Current Stockholders Profile (as of filing date) 1. 2. 3 SCHEDULE 8: Projected Sales*
Year 1 2 3 4 5 Service type a. b. a. b. a. b. a. b. a. b. Projected annual volume Annual Revenue

100

Number

Date Issued

Total Annual revenue (in Million Pesos)

*Modify as appropriate

ATTACHMENTS: A) Project Site- should be shown in Google Map (Satellite View). Sketches are not acceptable. (Also, indicate previously registered projects, if any). B) Schematic Diagram showing Business Model of the Activity being registered (clearly indicate how the company will earn revenues and make a profit) C) Other Sector-Specific requirements: List of BOI-registered Projects DOT Endorsement (if applying under Tourism Act) Copy of License to operate issued by DOH and Philhealth Accreditation (if applying under Hospital/Medical Services listing, as post-registration condition)

D) Projected Income Statement with ITH OTHER DOCUMENTARY REQUIREMENTS SEC Registration (for new applicant)/amendments, if any) Latest Audited Financial Statements (for existing corporations) Latest General Information Sheet (GIS) submitted to SEC Board Resolution Authorizing Officer to represent the company (see format) Publishers Affidavit of Publication of Notice For projects applying as Expansion, last three years AFS and ITR.

SAMPLE FORMAT FOR SECRETARYS CERTIFICATE

SECRETARYS CERTIFICATE I, (name of Corporate Secretary), of legal age, Filipino, being the duly elected and qualified Corporate Secretary of (name of applicant firm), a corporation duly organized and existing under the laws of the Philippines, with office address at (office address of applicant firm), under oath, do hereby certify that at the special meeting of the Board of Directors of the Corporation held on (date of special meeting), the following resolution was unanimously adopted: RESOLVED, that (name of officer of firm), (position of officer) be as it hereby, authorized to transact, execute and sign all documents in behalf of the Corporation pertaining to its application for registration under the Omnibus Investments Code of 1987 (Executive Order No. 226) with the Board of Investments for its (proposed project activity) as (new)(expanding)(existing) (export) producer of ____________ under the 20___ Investment Priorities Plan. IN WITNESS WHEREOF, I have hereunto affixed my signature this __________ day of _____________, 20___ at __________________________.

Corporate Secretary Subscribed and Sworn to before me this __________________ at _______________, affiant exhibited to me his CTC No. ____________________ issued on ___________________ at ___________________.

Notary Public

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

Projected Income Statement (with ITH)

5

In '000 PhP
YEAR 1 Total Sales/Revenue Less: Sales Discounts Net Sales/Revenue Less: Cost of Goods Sold Gross Profit on Sales/Revenue Less: Operating Expense Net Profit (Loss) from Operations Add: Other Income, Net Less: Interest Expense Net Income Before Tax (NIBT) Less: Corporate Income Tax (30% of NIBT) Add: Income Tax Holiday (for Qualified Activities) Net Income After Tax (NIAT) YEAR 2 YEAR 3 YEAR 4 YEAR 5

(Name of Applicant Enterprise) Projected Operating Expenses In '000 PhP

YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 Selling Expenses: Salaries and Wages Fringe Benefits Sales Commissions Sales Tax Advertising and Promotion Delivery Expense Representation and Entertainment Normal Depreciation Other Taxes and Licenses Total Selling Expense General and Administrative Expenses: Salaries and Wages Fringe Benefits Normal Depreciation Amortization of Pre-Operating Expense Office Supplies Other Taxes and Licenses Communication, Light and Water Transportation and Travel Total General and Administrative Expense Total Operating Expenses