Form-AL-01

SECURITY AGENCY APPLICATION FORM (Revised 2016)

IMPORTANT: FILL DATA REQUIRED COMPLETELY, ACCURATELY AND LEGIBLY. ALL ENTRIES MUST BE
TYPEWRITTEN AND WILL BE ENCODED IN THE DATABASE SYSTEM OF SOSIA.
BUSINESS PROFILE
BUSINESS NAME:
COMPANY E-MAIL ADDRESS:
BUSINESS ADRESS:
CONTACT NR/ CP NR:

SECURITY SERVICES PROVIDED: [ x] PRIVATE SECURITY [ ] ARMORED SECURITY

[ ] PRIVATE DETECTIVE [ ] COMPANY SECURITY FORCE
NATURE OF BUSINESS:
[ x ] SOLE PROPRIETORSHIP [ ] PARTNERSHIP [ ] CORPORATION
BRANCHES: NUMBER OF BRANCHES: INVESTMENT CAPITAL:
____ Luzon ____ Visayas ___ Mindanao ( ) 1 ( ) 2 ( )3 ( ) 4 P1,000,000.00
LICENSE TO OPERATE APPLIED FOR: ( )Temporary(New) ( ) Temporary - Regular (x) Regular
( ) Temporary/1st Extension ( ) Temporary/2nd Extension
MANAGEMENT PROFILE
Name of Licensee: S.O. License Validity:
Address: Contact Nos.
A. Administration/Operation
Name License Validity Position
SECURITY DIRECTOR
SECURITY STAFF DIRECTOR FOR OPERATION
SECURITY STAFF DIRECTOR FOR
ADMINISTRATION
B. Board of Directors (for Corporation only)
Name Position

SECURITY PERSONNEL and FIREARMS PROFILE

Nature of Profession Number FAs Caliber/Make Number

LICENSE PROFILE (For old Applicant only)

License to Operate Number Authority and Date Granted Expiry Date

CRIMINAL/ ADMINISTRATIVE CASE PROFILE

Has licensee/agency been charged criminally/administratively/civilly in any court or quasi-judicial

body within the Philippines? ______ . ( If Yes, please specify below)
Nature of Case Where and When Filed Disposition

CERTIFICATION AND UNDERTAKING

I hereby certify that, all statements provided and documentary requirements attached herein are true, correct, valid and authentic
and any misdeclaration/falsity stated therein shall be a basis for the cancellation/revocation of my License to Operate (LTO) without
prejudice to the filing of criminal and/or civil case against me.
I hereby undertake to renew the License to Operate (LTO) two (2) months before the date of expiration of the same. I understand
that, pursuant to Section 11 (c) part 2, Rule IV of 2003 Revised Implementing Rules and Regulation of R.A. No. 5487, as amended, that
failure on my part to renew the LTO sixty (60) days after the expiry date, shall cause its automatic cancellation and subsequent issuance of
Cease to Operate Order against PSA. Consequently, all firearms shall be deposited in the storage of FEO or nearest FESAGS or Police
Station pursuant to RA 10591.
SUBSCRIBED AND SWORN TO BEFORE ME THIS _____ DAY
OF _____________________ APPLICANT EXHIBITED TO ME _____________________
HIS/ HER CTC NO. ______________ ISSUED IN __________ LICENSEE
_______________ ON ______________.
DOC NO: _____
PAGE NO:_____
BOOK NO:_____
Series of _____ NOTARY PUBLIC
Form-AL-01

ME HIS/HER COMMUNITY TAX CERTIFICATE NO.

____________ ISSUED IN __________________
ON ________________________.