Department of Public Works and Highways Registry of Contractors for Civil Works Projects Contractors Confidential Application Statement

for Registration
(Please read the attached Instructions)

I,

of legal age, with postal address at , after having been duly sworn in

accordance with the law, hereby depose and say: 1. That I am the of the duly authorized to make this statement, as evidenced by the attached written authority from the proprietor/governing board of the firm, 2. That I hereby present the following Information for Registration with the Department of Public Works and Highways.

A. GENERAL INFORMATION
1. Name of Firm/Company : a. Head Office Address : Number: Municipality/City: Postal Code: b. Mailing Address : Number: Municipality/City: Postal Code: c. Telephone Number : d. Fax Number : e. Email Address : f. Company TIN : 2. Foreign Contractors Only a. Nationality : b. Philippine Address : Number: Municipality/City: Postal Code: c. Telephone Number : d. Fax Number : e. Email Address : f. Percentage of Filipino Ownership : Street Name: Province: Country: Street Name: Province: Country:

Region ____

Region ____

Street Name: Province:

Region

(if applicable)

3. Person managing the affairs of the firm: Attach Annex A a. Name : b. Designation : c. Telephone Number : d. Specimen Signature :

4. Authorized Liaison Officer: Attach Annex B Name 1. 2. Designation Telephone Number Specimen Signature

1. 1. 1.

2. 2. 2.

3. 3. 3. 3.
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B. LEGAL ASPECTS
1. PCAB License Information (if applicable) Contractor Particulars
(Please refer to your PCAB License)

Sole Proprietor: Attach Annex D Partnership: Attach Annex E Corporation: Attach Annexes E and F

Head Office Location (Region):

License Particulars License First Issue Date (mm/dd/yy): Principal Classification: ___/___/___ License No.: From: ___/___/___ Category: Other Classifications To: ___/___/___ Validity Period of this License/Renewal (mm/dd/yy):

Registration Date (mm/dd/yy): Kinds of Project:

___/___/___

Number: From: ___/___/___ Respective Size Ranges: To: ___/___/___

Validity Period of this Registration (mm/dd/yy):

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2. Ownership
NAME (S) of Owner/Stockholders Tax ID Number (TIN)

3. City/Municipal Business Permit: Attach Annex C 4. BIR Tax Clearance (per EO 398, series of 2005): Attach Annex H Date issued: Validity period: Tax Identification Number: 5. PhilGEPS Registration. Attach Annex M Date issued: Validity period: Certificate No.:

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C. TECHNICAL ASPECTS (Contractors Work Experience)

1. List of all contracts completed by the contractor both in government and in the private sector: Attach Annex I Participation % Contract Date Start mm/dd/yy Actual Completion mm/dd/yy Major Categories of Work Code Refer to Attachment A Dimension Refer to Attachment A Total As Built Cost Per Major Work Category

Contract ID

Contract Name

Owner

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2. List of all on-going contracts including those already awarded but not yet started, both in government and in the private sector: Attach Annex J NOTE: Cost must be in Philippine Pesos computed on the date of the signing of the contract. Participation % Contract Date Start mm/dd/yy Actual Completion mm/dd/yy Percent WA TE Major Categories of Work Code Refer to Attachment A Estimated Total Cost per Major Work Category

Contract ID

Contract Name

Owner

Dimension

Key: WA = Work Accomplished

TE = Time Elapsed

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D. FINANCIAL ASPECT (Amounts shall be in Philippine Pesos): Attach Annex K CY - 1 Total Assets Current Assets Total Liabilities Current Liabilities Total Net Worth Current Net Worth Gross Annual Turnover (construction) Note: CY - 1 = Current Year minus one Taxpayer Identification Number (TIN) CY - 2 CY - 3 CY 4 CY - 5

E. AFFIDAVIT
I hereby certify that all information provided herein, including the annexes and enclosures thereto, is true and correct, and I hold myself liable, criminally or civilly, for any misrepresentation or false statement made herein. I hereby authorize the Department of Public Works and Highways to investigate and verify the said information. IN WITNESS THEREOF, I have hereunto affixed my signature this 20 , at , Philippines.
(Affiant)

day of

(Republic of the Philippines PROVINCE/CITY OF

) ) ACKNOWLEDGMENT

SUBSCRIBED AND SWORN to before me this

day of

, 20

, at

, affiant exhibited to me his/her Residence Certificate No. issued on at , Philippines.

(Notary Public)

Until 31 December 20 PTR No.: Issued at: Issued on: TIN No.: Doc. No. : Page No. : Book No. : Series No.:

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CONTRACTORS CONFIDENTIAL APPLICATION STATEMENT FOR REGISTRATION

INSTRUCTIONS FOR CONTRACTORS APPLICATION 1. The Contractor-Applicant shall accomplish/answer all items in the Application Statement using the English language. Answers must be given to all questions in the aforesaid statement. All blanks shall be properly filled in. If necessary, additional sheets may be added to the form or, if the form has limited space, it can be reproduced and enlarged to suit the Contractor-Applicants needs. Documents submitted on forms or in any format other than that prescribed in the aforesaid Statement shall be considered non-complying and will be rejected outright. Forms that may require attachments shall be clearly marked, i.e., Attachments to Form No.1; Attachments to Form No. 2, etc. The information/data submitted by the Contractor-Applicant are to be used by the DPWH in determining, according to its judgment, the eligibility and qualification of the Contractor. In view thereof, Contractor-Applicants are encouraged to communicate with the DPWH for any clarification or interpretation of the documents. Requests for reconsideration will not be entertained on any erroneous interpretations or conclusions made by the Contractor-Applicant. A Contractor-Applicant submitting its qualifications as prospective Contractor for review and consideration waives any claim against any decision thereon. The signing by the Contractor or the duly authorized representative of the Contractor-Applicant Application Statement for Registration acknowledges the truth and correctness of all statements made therein; otherwise, the Contractor shall be liable for perjury as provided in the Revised Penal Code. Aside from the main Contractors Confidential Application Statement for Registration the following documents shall be annexed to and form part of the Statement: Annex A Annex B Annex C Annex D Annex E Annex F Annex G Annex H Appointment or authority of the Authorized Manager of the Organization with specimen signature duly notarized Appointment or authority of the officially designated Liaison Officer with specimen signature duly notarized and Two (2) valid IDs (Xerox) showing his/her proper identification. Certified Copy of Contractors PCAB License for the current year Certified Copy of Registration of Business Name (DTI) Certified Copy of SEC Certificate of Registration Certified Copy of Articles of Incorporation (if applicable) Certified true copy of valid and current Mayors Business Permit Certified Copy of BIR Tax Clearance, using BIR Form 17.14B Certified true copy of Contract Agreement and of Certificate of Completion/Acceptance from the Implementing Office / Owner, with Contract ID Number (pursuant to DO No. 241, Series of 2001, dated 11/19/01), scope of work and Contract cost for completed Contracts; and approved plans, and/or proofs of payments (vouchers), building permit and certificate of occupancy in case of building projects of private ownership. Certified true copy of Contract Agreement from the Implementing Office / Owner, with Contract ID (pursuant to DO No. 241, Series of 2001, dated 11/19/01), scope of work, Contract costs and a statement from the Implementing Office as to %WA and %TE for all ongoing Contracts, including private Contracts and those already awarded but not yet started, including a certified true copy of NTP. Audited Financial Statement as reflected in Contractors Income Tax Return stamped received by the Bureau of Internal Revenue for the last five years. Letter authorizing verification of integrity of the Registration documents. Certified Copy of PhilGEPS Registration Certificate

2.

3.

Annex I

Annex J

Annex K Annex L Annex M

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4. Each page of the annexes, attachments and other supporting documents shall be marked in the right top corner, e.g., Annex A, page 1 of 5; Annex A, Page 2 of 5; etc. 5. The Contractors Confidential Application Statement for Registration, including Annexes, shall be submitted in ONE (1) envelope. The envelope should be captioned Application for Registration and submitted to the DPWH Head Office: Procurement Office for Civil Works (POCW). All documents submitted shall be treated as confidential and will not be returned. The DPWH will inform all applicants of the result of their application. It reserves the right to accept or reject any application without any liability to the affected applicants or any obligations to inform the applicants of the grounds for the action taken thereon.

6.

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Attachment A TABLE OF MAJOR CATEGORIES OF WORK

Code BCB BCC BCS BCP BEL BIH BIL BRB BRC BRP BRR BRS BRT FEN FEX FHD FHG FHN FHP FHR FHW MBG MFC MRB PHC PHW RCA RCG RCP REC RRA RRG RRP TEA TEG TEP TES TEP-S TLS Category of Work Description Bridges- Construction- Bailey Bridges- Construction- Concrete Bridges- Construction- Steel Bridges- Construction- With Bored Piles Building Electrical Buildings / Industrial Plant High Rise Buildings / Industrial Plant Low Rise Bridges- Rehabilitation- Bailey Bridges- Rehabilitation- Concrete Bridges- Rehabilitation- With Bored Piles Bridges- Rehabilitation- Retrofitting Bridges- Rehabilitation- Steel Bridge Rehabilitation-Timber Perimeter Fence Foundation Excavation Flood Control / Hydraulics / Dams Flood Control / Hydraulics / Dredging Flood Control / Hydraulics / Drainage Flood Control / Hydraulics / Pumping Station Flood Control / Hydraulics / River Control Flood Control / Hydraulics / Water Supply Maintenance of Buildings Maintenance of Flood Control Maintenance Roads and Bridges Ports / Harbors Causeway Ports / Harbors Wharf Roads- New Construction- Asphalt Roads- New Construction- Gravel Roads- New Construction- PCCP Reclamation Works Roads- Rehabilitation- Asphalt Roads- Rehabilitation- Gravel Roads- Rehabilitation- PCCP Traffic Engineering- Signage Traffic Engineering - Guardrails Traffic Engineering- Pavement Markings Traffic Engineering- Signalization Traffic Engineering Pavement Studs Transmission Lines Unit of Measure linear meter (lm) lm lm lm set storey storey lm lm lm lm lm lm square meter (sq. m) cu.m cu.m cubic meter (cu.m) lm unit lm lm storey cu.m kilometer (km) lm lm km km km cu.m km km km piece piece lm set piece km

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Letter Authorizing Investigation of Integrity of the Registration Documents ANNEX L

LETTER AUTHORIZING VERIFICATION OF THE INTEGRITY OF REGISTRATION DOCUMENTS

[Name of the Head of the Procurement Office for Civil Works] [Position] Department of Public Works and Highways [Address] Dear Sir/Madame:
(Name of Firm)

I hereby request that my application for inclusion of the above-mentioned firm in the DPWH Registry of Contractors for Civil Works be approved. I am fully aware that: 1. all documents submitted in support of this application are subject to verification by DPWH; and 2. any discovered misrepresentation of information and/or manifestations of fraud on the application documents submitted by our firm, applicant, or its Authorized Representative/Agent/Liaison Officer shall be subjected to investigation which may result in the disapproval of my application, denial/suspension/revocation of this application and blacklisting of our firm and myself as its Authorized Managing Officer.
(Signature over Printed Name)

Authorized Managing Officer Republic of the Philippines) )S.S. ACKNOWLEDGMENT SUBSCRIBED AND SWORN to before me this Certificate No. issued on day of , 20 , at , affiant exhibited to me his/her Community Tax at , Philippines.
(Notary Public)

Until 31 December 20 PTR No.: Issued at: Issued on: TIN No.: Doc. No. : Page No. : Book No. : Series No.:

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