DSWD-RLA Form 2

Republic of the Philippines

Department of Social Welfare and Development
APPLICATION FOR REGISTRATION AND LICENSING OF
SOCIAL WELFARE AND DEVELOPMENT AGENCIES

Date: _______________________
Type of Application :
(Please check the appropriate box)

Registration

Peoples Organization

Status of Application:

New Application

Renewal
DSWD Previously Issued

SWD Network

Certificate No: ____________

Date of Issuance: ___________

Residential-based Agency

More than one Region/

Nationwide

Resource Agency

Registration and Licensing

Scope/Coverage:

Date of Expiration: ___________

Community-based Agency

Regional
Service Delivery Mode

Residential-Based

Community Based

Child Placing Agency

Resource Agency providing direct services
I. Identifying Information:
1. Name of Agency:
_________________________________
_________________________________
_________________________________

2. Business Address:
______________________________________
(No., Street/Subdivision, Barangay)

______________________________________
(Municipality/City)

3. Agency Head
_________________________________

______________________________________

4. Position Title/Designation:
_________________________________

5. Telephone/Mobile/Fax Nu1mbers
_____________________________________

6. E-mail Address:
_________________________________

7. Website:
_____________________________________

7. Registration/Permit No:
71. SEC No: ___________________

8. Date of Issuance of Registration/Permit

8.1 SEC Issued: ________________________

(Province)

Reminder: Any private SWDA that intends to engage or is currently engaged in social welfare and development activities
shall apply for registration or registration and license to operate with the concerned DSWD Office within six (6) months after
its registration with the SEC or with CDA that gives juridical personality to an agency to operate in the Philippines.
(Please use additional sheet/s, if necessary)
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7.2. CDA No. ____________________

7.3. Mayors Permit No. ____________

8.2. CDA Issued: ________________________

8.3. Mayors Permit Issued: ________________

II. Specific Objectives of the Agency (pls. state):

1. ____________________________________________________________________________
2. ____________________________________________________________________________
3. ____________________________________________________________________________
4. ____________________________________________________________________________
5. ____________________________________________________________________________
6. ____________________________________________________________________________

Others
(Specify)

Disasters
Victims

Community

Family

PWD

Older
Person

Women

Youth

Children

Municipality

City/
Province

Region

III. Program Profile (Please indicate all the programs and services for implementation/operation and/or
being implemented/operated by the applying SWDA):
Area of
Target Clientele
Type of
Coverage/Location
(Please check the appropriate column)
(pls. specify)
Programs and
Services per
Service Delivery
Mode
1. Direct Program/s (pls. specify all the programs and services that is directly provided to the clientele per area of operation)
a. Community-based

b. Residential-based (pls. indicate specific name of each facility and services provided to the clientele)

DSWD RLA Form2 (application for registration & license)

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Area of
Coverage/Location

Target Clientele
Others
(Specify)

Disasters
Victims

Community

Family

PWD

Older
Person

Youth

Children

Municipality

City/
Province

Women

(Please check the appropriate column)

(pls. specify)

Region

Type of
Programs and
Services per
Service Delivery
Mode

2.Indirect Program/s (Please specify all those are supportive activities in the delivery of social
welfare and development programs and services to the disadvantaged sector/s).
a. Funding

b. Training/Capability Building

c. Technical Assistance

d. Research

e. Advocacy/IEC Development

d. Others

IV. Personnel (current year)

No and Composition
Technical Staff
of Staff Complement

Administrative Staff

Registered
Social Worker

Community
Development Worker

Full time/
Regular Staff

Part time Staff

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Volunteer Staff

V. Budget:
1. Annual Budget (Latest):_______________________________________________________
2. Source of Funds: (Please specify the SWDAs specific sources of funds whether government or
private organizations/individuals, local and/or international/foreign including other resource
generation activities with the corresponding amount of funds in peso value.)
a. Local Source

Peso Value

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

b. Foreign Source

Peso Value

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

I hereby certify that the information on this application form is true and complete.
________________________________________________________________________
(Signature Over Printed Name of the Agency Head or Authorized Representative)

______________________________________________________
(Position/Designation of the Agency Head or Authorized Representative)

________________________________
(Date)
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