(To be filled up by BIR) DLN:  

Republic of the Philippines Department of Finance Application for Authority to Print

Bureau of Internal Revenue
Receipts and Invoices
2
AT
3
P
Fill in all applicable white spaces. Mark all appropriate boxes with an “X” RD
AP
1 Taxpayer’s Identification Number (TIN) O
PLI
Co
He ED
277 555 493 0001 FO
deX 
- - - ad Bra
Offi Name forRNon-Individual)
4 Registered Name (Last Name, First Name, Middle Name for Individual)/(Registered nch
SALIGUMBA YEHLEN FRANCIS REYES ce Offi
5 Trade/Business Name, if applicable ce
YEHLEN FRANCIS R. SALIGUMBA, M.D.
6 Business Address (Indicate applicable complete head or branch office address)
RM 1131 MEDICAL ARTS BLDG. ST. LUKES MEDICAL CENTER 32ND ST. COR. 5TH AVE. BONIFACIO GLOBAL CI
11
6A Dat
FORT BONIFACIO TAGUIG CITY e of
ZIP
7 Contact Number 8 Email Addressohmassociatescpa@gmail.com10 Printer’s Accreditation
Acc Number
Co
958-5466 de redi
Accredited Printer’s Details tati
9 Printer’s TIN on
(MM/
DD/Y
YYY)
912 - - - 0 190000000005 01  
61
12 Printer’s Name  3
05First Name, Middle0Name for Individual)/(Registered Name for Non-Individual)
(Last Name,
    
2
LEBIOS, PERCY D. 6 0 9 18
M
13 Printer’s Business Address (Indicate applicable0complete head or branch office address)
157 JP RIZAL ST. BAGONG SILANGAN, QUEZON CITY 0 P 13
2 A
0 ZIP
Co
de
14 Contact Number 15 Email
430-7093 Address

Details of Application for Receipts and Invoices

16 Manner of Receipts/Invoices Bound Loo Oth
X 
17 Description of Receipts and Invoices se ers
A. For Principal Receipts and Invoices Lea
f
Description TYPE (ATT NO. OF NO. OF SETS PER NO. OF COPIES
BOXES/BOOKLETS PER
ACH
VAT .NON-VAT LOOSE BOUND BOX/BOOKLET SET
ADD
OFFICIAL RECEIPTS ITIO X 10 5  0 0 2
NAL
SHE
B. For Secondary Receipts and Invoices TYP ET/S
NO. OF
BOXES/BOOKLETS
NO. OF SETS PER NO. OF COPIES
PER
Description E IF
NEC
ESS VAT .NON-VAT LOOSE BOUND BOX/BOOKLET SET
18 Declaration ARY
)
I declare, under the penalties of perjury that this application has been made in good faith, verified by me and to the best of my knowledge and belief, is true and correct,
pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof. Further, I give consent to the
processing of my information as contemplated under the *Data Privacy Act of 2012 (RA No. 10173) for legitimate and lawful purposes.
   YEH NFRANCIS R. SALIGUMBA                
LE REPRESENTATIVE
TAXPAYER/AUTHORIZED Title/Position of Signatory
(Signature over Printed Name)           For Manual Loose Leaf Receipts/Invoices:
*Note: The BIR Data Privacy Policy is in the BIR website (www.bir.gov.ph)          
ATTACHMENTS:
For Manual Bound Receipts/Invoices:          

          

         
Dat
e of
Rel
eas
e of
Aut
hori
 Final and clear sample of Principal and Supplementary Receipts/Invoices; and Permit to Use Loose-Leaf Official Receipts or Sales Inv
Photocopy of last issued ATP or PCD; or any booklet from the
last issued ATP for subsequent application. Final and clear sample of Principal and Supplementary
Photocopy of last issued ATP or PCD; or any booklet fro

Only the head office shall file the “Application for Authority to Print Receipts and Invoices (ATP)”. One (1) application should be filed and one (1) permit should be issued fo
branch). The data that should appear in the ATP are the data pertaining to the establishment
that will use the receipts/invoices.
 BIR
y to Print For
m
No.

1
9
0 039

6
Jan
uar
y
201
BONIFACIO GLOBAL CITY 8
(EN
CS)

2019

NO. OF COPIES SERIA

PER L NO.
STA END
RT 05
00 00
PER
01
NO. OF COPIES
SERIA
L NO.

STAR END
T Stamp of BIR Receiving Office and Date of
d belief, is true and correct, Receipt
I give consent to the

(MM/
DD/
YYY
Y)
se-Leaf Official Receipts or Sales Invoices;
mple of Principal and Supplementary Receipts/Invoices; and
ssued ATP or PCD; or any booklet from the last issued ATP for subsequent application.

and one (1) permit should be issued for every establishment (head office or each