APPLICATION FORM FOR BIR-BROKER CLEARANCE CERTIFICATE (BCC)

for NON-INDIVIDUAL
To be accomplished and signed by the authorized Key Officer/Board Member as indicated in the latest SEC
Revised Sept 2016 General Information Sheet

NAME OF APPLICANT :

TAXPAYER IDENTIFICATION NUMBER (TIN) : E-MAIL

ADDRESS :

PRINCIPAL PLACE/HEAD OFFICE OF BUSINESS :

CONTACT NUMBER :

LINE OF BUSINESS : PSIC:

NAME OF KEY OFFICER (FOR NON-INDIVIDUAL) :

POSITION/DESIGNATION : TIN:

ENCLOSED ARE THE FOLLOWING SUPPORTING DOCUMENTS TO THIS APPLICATION (PLEASE CHECK):

_____ 1. LIST OF BROKER-EMPLOYEES/BROKER-REPRESENTATIVES

_____ 2. PHOTOCOPIES OF IDENTIFICATION CARDS OF LISTED BROKER-EMPLOYEES/BROKER-REPRESENTATIVES
_____ 3. ORICINAL COPIES OF CERTIFICATES OF GOOD STANDING ISSUED BY PRC TO BROKER-EMPLOYEES/BROKER-
REPRESENTATIVES LISTED IN ITEM NO. 1
_____ 4. CERTIFIED TRUE COPY OF LATEST MAYOR’S BUSINESS PERMIT OR DULY RECEIVED APPLICATION FOR SUCH
PERMIT
_____ 5. PROOF OF OWNERSHIP/LAWFUL OCCUPANCY OF PRINCIPAL PLACE/HEAD OFFICE OF BUSINESS (i.e., ELECTRIC,
WATER OR FIXED TELEPHONE LINE)
_____ 6. DELINQUENCY VERIFICATION CERTIFICATE ISSUED BY THE CONCERNED LARGE TAXPAYERS
SERVICE/NATIONAL/REGIONAL OFFICE WITH A VALIDITY PERIOD OF ONE (1) MONTH FROM DATE OF ISSUE
_____ 7. ORIGINAL COPY OF THE CERTIFICATE OF GOOD STANDING ISSUED BY THE SECURITIES & EXCHANGE
COMMISSION
_____ 8. ORIGINAL COPY OF THE SECRETARY’S CERTIFICATE CERTIFYING THAT A BOARD RESOLUTION WAS PASSED
AUTHORIZING ANY KEY OFFICER/BOARD MEMBER INDICATED IN THE SEC GENERAL INFORMATION SHEET TO SIGN
THE APPLICATION FORM TOGETHER WITH HIS/HER SPECIMEN SIGNATURE, PICTURE AND PHOTOCOPY OF CALID
GOVERNMENT-ISSUED IDENTIFICATION CARD

I HEREBY DECLARE, UNDER THE PENALTY OF PERJURY, THAT THIS APPLICATION HAS BEEN MADE IN GOOD FAITH, AND
THAT THE REPRESENTATIONS INCLUDING THE ACCOMPANYING SUPPORTING DOCUMENTS HAVE BEEN VERIFIED BY ME AND TO
THE BEST OF MY KNOWLEDGE, BELIEF, AND INFORMATION ARE CORRECT, COMPLETE AND TRUE.

____________________________________
Signature over Printed Name of Authorized Officer

SUBSCRIBED AND SWORN to before me this ______ day of ___________________ 20______ in

____________________________________, applicant exhibiting to me his/her competent evidence of identity (government-
issued identification card) No. _________________, bearing his/her photograph and signature, issued on
______________________ by ____________________ at ____________________________________.

NOTARY PUBLIC