Republic of the Philippines Department of Labor and Employment REGIONAL OFFICE NO. .........

APPLICATION FOR: ( ) REGISTRATION

( ) RE-REGISTRATION

Series of 20............ Application No. ...........

............................... Date

1. Name of Establishment:...................................................................................................... 2.
Address:..........................................................................................................................

Street City/Municipality Province

3. Name of Manager/Owner:.................................................................................................
4. Address of Manager/Owner:.................................................................................................... 5.
Nature of Business & Product Manufactured, Service Rendered or Merchandise Sold: (Example

Manufacturing-Textile; Construction-Building; Agriculture-Production of Livestock, etc.: Forestry-Logging;

Services-Generation and Distribution of Electricity; Commerce-Lumber and Construction Materials;
Wholesale or Retail) ............................................................................................................................
............................................................................................................................

6. Number of Employees:.................................GRAND TOTAL.......................................................

Minors

Filipinos Resident Alien Non-Resident Alien Below 15 15 Below 18

Male

Female

Total

7. Name and Address of Labor Union if any:................................................................................... 8.

Technical Information:............................................................................................................

1. Machinery, Equipment and Other Devices in Use: (Example: Machinery, Drill Press, Circular Saw,
etc.: Boiler Pressure Vessel; Internal Combustion Engine Diesel, Gasoline......................
2. Materials Handling Equipment and Devices: Example: Handtrucks, Power Trucks, Conveyors, etc.)
3. Chemicals or substances used or handled.........................................................................

9. If branch unit, name of parent establishment..............................................................................

Location......................................................................................................................................

10. Current Capitalization: P................................................ Total Assets................................... FOR RE-

REGISTRATION, ACCOMPLISH ALSO
11. Past Application Number............................................... Date of Application......................... 12. If
Changing Name of Establishment, State Former Name:........................................................... 13. If
Changing Location, Give Past Address:..................................................................................

I hereby certify that the above information is true and correct. RECEIVED AND APPROVED
 Date.......................................................
Enforcing Officer Owner/Manager

.............................................................. TIN Regional Director