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Form No.

Republic of the Philippines
Department of Labor and Employment


1. Business Name: TIN

2. Business Address:
3. Telephone No. Fax: Email:
4. Contact Person and Position:
5. Areas of Operation:
6. Nature of Business: 7. Industries to be covered
8. Number of Regular Workers: Male Female
9. Proof of compliance with substantial capital requirements
10. Names Positions and Addresses of Officers and Staff (use additional sheet if necessary):
Names of Officers/Staff Position Postal Address

Number of
Number of
Name and Address Services Personnel Description of the
Nature of Covered in each
of Oient/Principal Provided to Assigned to each Phase of the
Business Phase of the
Clients/Principa I client Contract Contract
Male Female Male Female


That I, _ _ _ _ _ _ _ __, Filipino, of legal age,----:-,:-~::-::-------~----==:----

name dvil status position

Of ---~~~~-------~
name of company
after having been duly sworn to in accordance with law, do

hereby depose and say:

1. That our company shall abide by all applicable laws and regulations of the Department of Labor and
2. That the remittances/payments to 555, HDMF, Philhealth, ECC and BIR have been made during the
reporting period;
3. That I have read and understood the contents of the foregoing application; and that contents
thereof are ture and correct to the best of my personal knowledge and based on authentic records.
In witness whereof, I have hereunto affixed my signature this _ day of 20_ in

(Affiant's Name /Signature)

SUBSCRIBED AND SWORN to before me this _day of --~20_. Affiant exhibited to me his/her
Residence Certificate No. issued at ____ on _ _ _ __

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

Note: All contracts entered into after this registration shall be reported to the DOLE Regional Office on or before the 1r:f'
day of the month immediately following the date of entry into contract.