PHILIPPINE BUSINESS REGISTRY SEC-REGISTERED COMPANIES APPLICATION FORM

A. SEC REGISTRATION INFORMATION 1. Business Type Stock Corporation General Partnership Foreign Non-Stock Corp (Please select one.) Non-Stock Corporation Limited Partnership Foreign Partnership Foreign Stock Corporation Professional Partnership 2. SEC Registration No. 3. SEC Registration Date 4. TIN (pre-generated issued by SEC)

5. Company Name B. BUSINESS DETAILS 6. House/Building No. 7. 8. 9. House/Building Name Street Barangay

10. Town/City 11. Province 13. Phone No. (Please put in area code) 15. Mobile No. C. PSIC and Other Details 17. Business Activities (Please check all that applies) 18. Main Business Activity (Select one among the business activities you chose above) 19. Indicate Main Product Handled/ Service Rendered 20. Total No. of Employees 14. Fax. No. (Please put in area code) 16. eMail Address 12. Region

Manufacturer/Producer Importer Manufacturer/Producer Importer

Service

Retailer Wholesaler Retailer Wholesaler

Exporter

Service Exporter

D. DOING BUSINESS AS (List down company names and please use another form if more than 5 )

E. INCORPORATOR/PARTNER DETAILS (At least 2 is required. If more than 2 incorporators, use another application form) MAIN INCORPORATOR/PARTNER 21. Position/Title: 22. First Name: 24. Last Name: 26. SSS Number: 28. TIN: 29. House/Building No. Page 1 of 2 23. Middle name: 25. Suffix: 27. Pag-ibig Number:

30. House/Building Name 31. Street 32. Barangay 33. Town/City 34. Province PARTNER/OTHER INCORPORATOR 36. First Name: 38. Last Name: 40. SSS Number: 42. TIN: 43. House/Building No. 44. House/Building Name 45. Street 46. Barangay 47. Town/City 48. Province 49. Region 37. Middle name: 39. Suffix: 41. Pag-ibig Number: 35. Region

F. AUTHORIZED REPRESENTATIVES (At least 1 is required. If more than 2 representatives, use another application form) Representatives Details 50. First Name: 52. Last Name: 54. Telefax Number: 56. SSS Number 57. Email Address: Representatives Details 58. First Name: 60. Last Name: 62. Telefax Number: 64. SSS Number 65. Email Address: 59. Middle Name: 61. Suffix: 63. Mobile Number: 51. Middle Name: 53. Suffix: 55. Mobile Number:

_________________________________ OWNERS Signature over Printed Name For DTI/SEC-PBR Kiosk Use Only TRN/ PBN Date Registered BN Certificate No. Office

________________________ Date Fee: OR Number: Recd by: Date Paid:

BIR Tax Identification No.

SSS Employer No.

PhilHealth Employer No.

PAG-IBIG Employer No.

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