EDD.1.F.

010
Revision 2, 01 December 2016

APPLICATION FOR REGISTRATION OF

ECONOMIC ZONE FACILITIES ENTERPRISE

_____________________________
Date
BGen CHARITO B. PLAZA (AFPR) MNSA, PhD

Director General
Philippine Economic Zone Authority

Madam:

In accordance with Chapter II, Section 12 (c) of Republic Act No. 7916, otherwise
known as the Special Economic Zone Act of 1995, as amended by Republic Act No.
8748, and its Implementing Rules and Regulations, I am applying for the registration of
_______________________________________________ as Economic Zone Facilities
Enterprise for the establishment, operation and maintenance of _____________________
_______________________________________________________ to be located at
___________________________________________________________________________.

The undersigned attest that the documents/information submitted are true and are correct and
that I assume full responsibility for any misrepresentation and/or violation thereof.

Attached hereto are:

1. Duly Accomplished and Notarized Application Form, Anti-Graft Certificate (R.A. 3019) and Applicant's
Undertakings
2. SEC Registration Certificate and Articles of Incorporation and By-Laws (including latest GIS)
3. Audited Financial Statements for the last three (3) years of operation, if applicable
4. Board Resolution/Special Power of Attorney/Secretary’s Certificate designating the company’s
authorized representative to PEZA
5. Project Description, which should provide, among others, development plan and schedule of the
proposed facilities
6. Site development plan and vicinity map reflecting its surroundings within one (1) kilometer radius of
the project site
7. Proof of land ownership or any document confirming the applicant’s authority to use the land subject
of the proposed facilities
8. Environmental Compliance Certificate issued by the Department of Environment and Natural
Resources, if applicable
9. Copy of the Building Permit, Occupancy Permit and latest Fire Safety Inspection Certificate issued by
the LGU for existing facilities
10. 3-year Projected Income Statement and Balance Sheet
11. Favorable endorsement from the economic zone developer/operator

Very truly yours,

 EDD.1.F.010
Revision 2, 01 December 2016

President/General Manager
 EDD.1.F.010
Revision 2.01 December 2016

Republic of the Philippines

PHILIPPINE ECONOMIC ZONE AUTHORITY
Building 5, DOE-PNOC Complex, Energy Drive, 34th Street, Bonifacio Global City, Taguig City
Trunk Line No. 551-3451 Loc. 213 & 214 / TeleFax No. 551-3440/E-mail Add: edd@peza.gov.ph

APPLICATION FOR REGISTRATION OF

ECONOMIC ZONE FACILITIES ENTERPRISE

Date Filed
O.R. No. / Date

A. APPLICANT
Company Name
TIN No.
Company Address
Telephone No.
Fax No.
Email Address
Website

B. AUTHORIZED REPRESENTATIVE
Name
Address
Telephone No.
Fax No.
Email Address

C. TYPE OF APPLICATION (Please Check)

New Ecozone Facilities Enterprise

Expansion/Additional Project

Site of Operation

Location _______________________________________________________
(Lot No. Block No. Phase No. )

Name of Ecozone _______________________________________________

3
 EDD.1.F.010
Revision 2.01 December 2016

D. PROJECT BRIEF

The Proponent

1. Name of Company
2. SEC Registration
Cert. of Registration No.
Date
Amendment (if any)
Nature
Date

3. Nature of Business

4. Incorporators

NAME NATIONALITY

Use separate sheet/s if necessary

5. Current Stockholders

AMOUNT OF AMOUNT OF
NO. OF
NAME NATIONALITY SUBSCRIBES PAID-UP
SHARES
SHARES SHARES

Use separate sheet/s if necessary

6. Principal Officers

NAME POSITION

4
 EDD.1.F.010
Revision 2.01 December 2016

Use separate sheet/s if necessary

5
 EDD.1.F.010
Revision 2.01 December 2016

7. Capital Structure a. Authorized PhP

b. Subscribed PhP
c. Paid-Up PhP

8. Corporate Nationality

9. Affiliate Company

NAME OF COMPANY CAPITALIZATION

PhP

Use separate sheet/s if necessary

10. Other Project Involvements

YEAR
NAME OF PROJECT DESCRIPTION
ESTABLISHED

Use separate sheet/s if necessary

The Land

1. Location
2. Land Area
3. Ownership/Right Over Land q Full Ownership q Lease Contract
q MOA q Joint Venture Agreement
q Others

6
 EDD.1.F.010
Revision 2.01 December 2016

The Project

1. Status of Development New development Under development

Existing/Fully developed

If new development
i) date of commencement
ii) expected date of completion

If under development
i) percentage completion
ii) date started
iii) expected date of completion

If existing/fully developed
i) date established
ii) occupancy rate
iii) line of business of occupants

2. Project Description

Building No. Land Area (in sq. m.) Gross Floor Area (in sq. m.)

Use separate sheet/s if necessary

3. Labor Requirements

Projected No. of Workers/Employees

Year
During Construction During Operations
1
2
3
Average

7
 EDD.1.F.010
Revision 2.01 December 2016

4. Proposed/Existing On-Site Utilities, Facilities and Amenities

a. Power System
i) Power source
ii) Power franchisee
iii) Power transmission and distribution
iv) Back-up power generation
◘ Source
◘ Capacity

b. Telecommunication System
i) Telephone provider
ii) No. of lines

c. Water Supply System

i) Source
ii) Distribution system

d. Sewerage and Drainage System

e. Sewage Collection, Treatment and Disposal

i) Wastewater collection

ii) Wastewater treatment

iii) Wastewater disposal

iv) Wastewater recycling

f. Solid Waste Disposal System

g. Fire Fighting System

8
 EDD.1.F.010
Revision 2.01 December 2016

h. Other Utilities, Facilities and Amenities

5. Proposed Improvements (for existing project, if any)

6. Estimated Project Cost Breakdown

COMPONENT AMOUNT
Land Acquisition Cost PhP
Land Preparation
Building Construction Cost
Other Costs

TOTAL PhP
Use separate sheet/s if necessary

6.a. Land Development Cost per sq.m.

6.b. Vertical Development Cost per sq.m.

7. Sources of Funds
SOURCE PERCENT SHARE

Use separate sheet/s if necessary

8. Prospective Locators (if any)

Company Name :
Proposed Activity :
Projected Employment :
Projected Investment :
Use separate sheet/s if necessary

9. Lease Rates

Done in the City/Province of ____________________________________________________________

9
 EDD.1.F.010
Revision 2.01 December 2016

this day of 20

___________________________
Affiant
____________________________
Designation

Republic of the Philippines )

) S.S.
Municipality/City/Province of

Subscribed and sworn to before me this day of 20

in the Municipality/City/Province of

Affiant exhibit to me his Residence Tax Certificate No

issued at on 20

_________________________________
Notary Public
Until December 31, 20______

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

10
 EDD.1.F.010
Revision 2, 01 December 2016

Projected Income Statement

Y1 Y2 Y3
Revenues
Less: Cost of Services Sold
Direct Materials
Direct Labor
Mfg. Overhead

Gross Profit
Less: Operating Expenses
Selling, General and Administrative
Cost
Research and Development Expenses

Operating Income
Less: Other Expenses
Interest Expense

Income Before Income Tax

Less: Provision for Income Tax

Net Income

Projected Balance Sheet

Y1 Y2 Y3

ASSETS
Current Assets:
Cash
Account Receivable
Inventories
Other Account Assets
Total Current Assets

Fixed Assets:
Gross Fixed Assets
Less: Accumulated Dep'n
Net Fixed Assets

TOTAL ASSETS

LIABILITIES and
STOCKHOLDERS' EQUITY
Current Liabilities
Accounts Payable
Accrued Expenses
Advances from Affiliates
Other current liabilities
Total Current Liabilities

Long-Term Liabilities
Other non current Liabilities

TOTAL LIABILITIES

STOCKHOLDERS' EQUITY
Paid-up Capital
Additional Paid-in Capital
Deposits on Subscription
Retained Earnings

TOTAL LIABILITIES and

STOCKHOLDERS' EQUITY
 EDD.1.F.010
Revision 2, 01 December 2016

APPLICANT'S UNDERTAKINGS

In applying for PEZA registration, the Applicant herewith makes the following representations and commitments:

1 . That the applicant is capable of operating, on a sound and efficient basis, and of contributing to the
objectives of the Philippine Economic Zone Authority in particular and to the development of the national
economy in general;
2 . That the project is economically, technically and financially sound;
3 . That the applicant proposes to engage, in good faith, in the creation of a market for its project/product;
4 . That the applicant has installed/undertakes to install an accounting system adequate to identify the
investments, revenues, costs and profits or losses of the project covered by this application separately from
the aggregate investments, revenues, costs and profits or losses of the other business activities of the
applicant not registered under Republic Act No. 7916, as amended by Republic Act 8748 or has
established/undertakes to establish a separate entity for the project/activities covered by this application if so
required by the Authority. (Applicable only if applicant is engaged or proposes to engage in undertaking or
activities in addition to the project covered by this application);
5 . That the applicant shall submit periodic reports and other information, pertaining to its activities in the
Ecozone that the Authority may require;
6 . That the applicant has read Republic Act No. 7916, as amended, and the Rules and Regulations adopted by
the PEZA and commits itself to abide by the provisions thereof as well as amendments thereto;
7 . The applicant will start and operate the project covered by this application within such reasonable time as
may be fixed by the Authority;
8 . That the applicant's Board of Directors has authorized the filing of this application in accordance with the
terms thereof if the applicant is a corporation;
9 . That pursuant to Section 2(p), Rule I of the PEZA Rules, the applicant's income derived within the ecozone
shall be subject to taxes under the National Internal revenue Code pursuant to Section 25 of the Act;

10 . That no Board member or officer of the Philippine Economic Zone Authority has an investment or any other
financial interest, direct or indirect, in the applicant's enterprise; and
11 . That there exists no dummy relationship between any of the stockholders and/or principal officers of the
applicant and any foreign individuals/business entity.

Done in the City/Province of

this day of , 20 .

Affiant

Designation
Republic of the Philippines )
City / Province of ) S.S.

Subscribed and sworn to before me this_________ day of ________________ , 20___ in the City/
Province of ______________________. Affiant exhibited to me his Resident Tax Certificate No. _____________
issued at ___________________________ on _______________, 20___

Notary Public
Until December 31, 20_____
Doc. No.
Page No.
Book No.
Series of 20
 EDD.1.F.010
Revision 2, 01 December 2016

ANTI-GRAFT CERTIFICATE

I, ___________________________________________, of legal age, President/General

Manager/Sole Proprietor of __________________________________________________ with
postal address at _________________________________________________________ after
having been duly sworn, depose and say:

That pursuant to the provisions of Section 3 and 14 of Republic Act 3019 (Anti-Graft Act),
the applicant enterprise, _________________________________________________ has not
given or promised to give, and will not give, any gift to any officer or employee of the PEZA in
connection with the filing and processing of this application, nor it will give such gift to any of said
officers or employees after approval of its application.

That based on the records of the applicant, no Board Member or Officer of the PEZA
has an investment or other financial interest, direct or indirect, in the applicant; and

That this certificate was made with the approval of applicant's Board of Directors or
Management.

Affiant

Subscribed and sworn to before me this__________ day of _____________, 20 _____ in

the City/Province of ________________. Affiant exhibited to me his Residence Tax Certificate No.
_____________________ issued at _______________________ on
_________________________.

Notary Public
Until December 31, 20_____

Doc. No.
Page No.
Book No.
Series of 20