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PCAB
PCAB-PAD-UPG-F01
Revision
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Eff. Date
6/22/2011
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PHILIPPINE CONTRACTORS ACCREDITATION BOARD

UPGRADING OF CONTRACTORS LICENSE

APPLICATION
REQUIRED ITEMS

The following pertinent documents and information shall be submitted in support of Upgrading of PCAB
license application.(Applicant may Initially fill out the check boxes subject for final validation by PCAB/DTIROG pre-screener)

A. LEGAL

Complied

Yes

No

NA

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3.1.3 Transportation & Construction Equipment - List of Construction and/or Transportation/Delivery

Vehicles/Equipment/Machineries/Plants owned by the company and registered in its
name, (Page 9 of 16);

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Certified copy by the LTO of the LTO Certificate of Registration and current Official
Receipt of Registration of newly acquired registrable Construction and/or
Transportation / Delivery Vehicles/Equipment

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Certified copy of Deed of Sale or sales invoices/official receipts for newly acquired
construction equipment/machineries/plants, or newly acquired construction equipment
3.1.4 Other Assets - (i.e. investment in Banks and / or Shares of stocks and other accounts)

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Certified copies of certificates of Stock, time deposits, & other pertinent proofs of
ownership of other assets

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1. Affidavit of Attestation / General Information (Page 3 of 16 and Page 4 of 16)

1.1
For change in address only: Business Permit, or any other official document showing the
new office address of the applicant;
1.2
SEC Certificate of Filing of Increase in Authorized Capital and Amended Articles of
Incorporation, if applicable;
1.3
Certified copy of subsequent amendments (if any) to Articles of Incorporation and/or ByLaws in case of Corporate or Partnership applicant
In case of corporate applicant with foreign content, proofs/documents showing that election of aliens
in the Board of Directors is allowed in proportion to their share in capital:
1.3.1 Original copy of Secretarys Certification as to the present composition of the firms
Shareholdings and Board of Directors showing the names, nationalities,shareholdings
of Stockholders and Directors;
1.3.2 Certified copy of the pertinent pages of the firms latest General Information Sheet
(GIS) submitted to SEC showing the updated list of stockholders and directors.
B. FINANCIAL
2. Certified copy by the BIR of the Quarterly Income Tax Return duly filed with the BIR covering the
income reported in the Audited Financial Statement submitted and official receipt evidencing
payment of tax on income earned during the interim period, if applicable;
3. Complete Financial Statements with accompanying Auditors notes dated within the last six (6)
months immediately preceding the filing of application (duly audited and signed on every page by
an Independent CPA with valid PRC-BOA accreditation) and a CD-R (compact disc recordable)
containing the firms Audited Balance Sheet & Income Statement in the prescribed template to be
uploaded by the CIAP-RID in CIAP database. The PCAB Financial Statement Forms A & B can
be downloaded from the DTI website www.dti.gov.ph.
3.1 In case of increase in networth:
3.1.1 Cash - Original copy of Bank Certification/Bank statement of account certified by Bank Manager
of cash deposits as of the Balance Sheet date;
Authorization to Depository Bank (Page 5 of 16)
(NOTE: Amounts in excess of
of 1% of the minimum networth required for the
contractors existing category or P 50,000 Reflected as Cash on Hand will be deducted
from the Networth if unsupported).
3.1.2 Land and Building - List of Land and Building/s owned by the company and registered in its name
(Page 8 of 16 );
Certified copy of TCT including back page for newly acquired land and/or condominium
which were not previously reported/submitted to PCAB.
Certified copy of Deed of Sale or Tax Declaration of newly acquired / newly constructed
building which were not previously reported / submitted to PCAB.

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PCAB
PCAB-PAD-UPG-F01
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3.2 If increase is due to appraisal of properties

3.2.1 Independent Appraisers Report duly licensed by the Professional Regulation Commission

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3.3 Schedules of Receivables and Inventory accounts if the values of the said accounts exceed 50% & 20%,
respectively, of the Contractors Networth per Audited Balance Sheet duly signed by AMO and certified
by External Auditor.(Page 11 of 16)

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6.6.1 For STE/s below 60 years old: Certified copy of the pertinent page of CCL (formerly SSS
Form R-3) submitted to SSS for the quarter immediately preceding the filing of application;

[ ]

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6.6.2 For STEs 60 years old and above: Certified copy of Certificate of Income Tax
Withheld on compensation (BIR Form 2316, formerly BIR W-2) for the taxable year
immediately preceding the filing of application issued by the firm to the employee
and duly stamped received by BIR/ or accredited bank.

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D.3. Self-stamped envelopes (One self stamped mailing envelope is required for each supporting
document submitted), or a prepaid courier pouch.

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D.4. Accomplished Affidavit for Firms Authorized Representatives

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4. Applicants Authorization to BIR & other government agencies to release information to PCAB

(Page 6 of 16) and (Page 7 of 16)

C. TECHNICAL
6.Current List of Sustaining Technical Employee/s - STE (Page 10 of 16) by applicable documents
(listed below) for each STE; :
For newly nominated STE/s:
6.1 STE Affidavit/s (Page 12 of 16) with a passport size picture/s of the new STE/s;
6.2 Certified copy of valid PRC ID of STE as licensed professional or original
Certification of Good Standing for those awaiting issuance of new or renewed PRC ID.
6.3 NBI clearance/s of new STE/s;
6.4 STE Affidavit/s of Construction Experience (Page 14 of 16);
6.5 Personal Appearance Form duly accomplished and signed by the STE/s appearing before
the designated officer of the PCAB or the nearest DTI regional/provincial office (Page 15 of
16).

For previously nominated STE/s:

6.6 STE Affidavit/s (Page 12 of 16);

D. OTHERS
D.1. Original Signature of AMO on each and every page of the application forms including supporting
documents.
D.2. PCAB Response Form (self-addressed and with sufficient stamps affixed)

FOR PCAB / DTI-ROG USE ONLY

No. of Prescreening
1st
2nd
3rd

Prescreening Results
[ ] Comply lacking items as listed in the Remarks
Accepted
[ ] Comply lacking items as listed in the Remarks
Accepted
[ ] Comply lacking items as listed in the Remarks
Accepted

REMARKS:
LETTER / ITEM NO.

COMMENTS:

Filed
[ ]
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[ ] PCAB Makati [ ] DTI-ROG

[ ] PCAB Makati [ ] DTI-ROG
[ ] PCAB Makati [ ] DTI-ROG

Pre-screener / Date

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PCAB
PCAB-PAD-UPG-F01
Revision
02
Eff. Date
6/22/2011
3 of
Page

In behalf of
AFFIDAVIT
OF ATTESTATION SF SALAZAR CONSTRUCTION
(Name of Firm)

holder of Contractor's License No. 36948, originally issued on August 27, 2013 and
last renewed for CFY 2014 to 2015, I hereby request for an upgrading of the company's
license category from D to C .
I certify to the completeness of the information/documents contained in this application
appertaining to the category/classification the company is applying for and that the
information/documents are true and correct.
I further certify that the business name and/or SEC registration of this firm is valid and
existing.
I certify furthermore that the SSS, Pag-IBIG, and PhilHealth contributions in favor of the
employees of this firm were remitted to concerned agencies.
I am fully aware that:
1. All documents submitted in support to this application are subject to
verification before PCAB action;
2. Any discovered misrepresentation of information and/or manifestations of
fraud on the application documents submitted by my firm applicant or its
Authorized Representative/Agent/Liaison Officer shall be subjected to
investigation which may result to the disapproval of my application,
denial/suspension/revocation of license and blacklisting of my firm and myself
as its Authorized Managing Officer; and
3. Unconfirmed information/documents submitted to support my firm's
qualifications shall be excluded for categorization/classification purposes.
4. The evaluation of my qualification shall be solely based on the documents submitted at
the time the application was filed/accepted by PCAB.
_______________________________
Authorized Managing Officer
Republic of the Philippines )
Province of ______________)
City/Municipality of ___________) S.S

(Signature over Printed Name)

SUBSCRIBED AND SWORN TO before me this ________ day of ___________________ 20____ at

______________________; affiant exhibited to me his Community Tax Certificate No.
_______________ issued at __________________ on _________________ 20 ___.
Doc. No.
Page No.
Book No.
Series of 20 __.

NOTARY PUBLIC
Until December 20 ____

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PCAB
PCAB-PAD-UPG-F01
Revision
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Eff. Date
6/22/2011
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CONTRACTORS GENERAL INFORMATION

Name of Firm: (as per SEC or DTI or CDA Registration)

SF SALAZAR CONSTRUCTION
Main Office Address

Tel./Fax No.

14-C Real Street, New Intramuros Village, Matandang Balara, Quezon City

02 - 3321723

If Provincial based, contact address in Manila, if any

Tel./Fax No.
N/A

N/A
Website

E-mail Address
Susansalazar18@yahoo.com

N/A

Type of Firm (please check):

[ ] Sole Proprietorship [ ] Partnership
[ ] Corporation
[ ] Cooperative
SEC / Business Name Registration No. Registration Date
Expiry Date
08/23/2010
08/23/2015
01156518
Firms SSS No:
Tax Identification No.
PhilHealth No.
PAG-IBIG No.
03-9264569-4
118-356-898-001
003000021286
202204890008
Principal
Classification:
Other
Classification/s:
Present Category
(encircle only one below)

(please encircle, if any)

General Building / General Engineering /

General Building / General Engineering /

Category Applied for

Trade / Specialty(please specify below):

Specialty(please specify):

___________________________________

Owners / Stockholders / Officers (for corporation / partnership)

NAME

POSITION

NATIONALITY

CAPITAL
SUBSCRIPTION

PAID-UP
CAPITAL

PERCENTAGE
Peso
value

Shares

N/A

Directors / Officers (for corporation only)

NAME

POSITION

NATIONALITY

ADDRESS

N/A

Certified Correct by:

_______________________________
Authorized Managing Officer
(Signature over printed name)

AUTHORITY TO VERIFY BANK ACCOUNT

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PCAB
PCAB-PAD-UPG-F01
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6/22/2011
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THE MANAGER
Anna Lourdes T. Lugtu
UnionBank Plaza, Meralco Ave.,
Corner Onyx & Sapphire Roads

Ortigas Center, Pasig City

Subject: Bank Account # 001440003558

Sir:
Please provide the Philippine Contractors Accreditation Board (PCAB), a
government agency under the Department of Trade and Industry, any information they
need regarding the subject account with your bank.
I am applying for a contractor's license from PCAB and part of their evaluation process
is the verification of bank deposits and other assets of an applicant.
This will serve as your authorization to release any information that may be requested
by PCAB regarding the above subject account.
Thank you.
Very truly yours,
Name of Firm:
____________________________
____________________________
By:_________________________
Type of Application: (Pls. check)
New
Upgrading
Renewal
Others, pls. specify
_______________________

Signature over Printed Name

of Authorized Managing Officer
or Authorized Signatory with the Bank

Date:_______________________

AUTHORITY TO VERIFY ITR / AFS FROM B.I.R.

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PCAB
PCAB-PAD-UPG-F01
Revision
02
Eff. Date
6/22/2011
6 of
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THE REVENUE DISTRICT OFFICER

Florante R. Aninag
3rd Floor, BIR Building, Quezon Avenue
Cor. Scout Santiago, Quezon City

Subject: Income Tax Return and Audited Financial Statement as of December 31, 2014
Sir:
Please provide the Philippine Contractors Accreditation Board (PCAB), a
government agency under the Department of Trade and Industry, any information they
need regarding the subject ITR and AFS filed with your office.
I am applying for a contractor's license from PCAB and part of their evaluation process
is the verification of ITR and AFS, of an applicant.
This will serve as a waiver on the confidentiality provision of Section 270 of the National
Internal Revenue Code of 1997 (memorandum circular No.28, 2006 dated May 08,
2006) and your authorization to release any information that may be requested by
PCAB regarding the above subject document/s.
Thank you.
Very truly yours,
________________________
Signature over Printed Name
of Authorized Managing Officer

Date:_______________________
Type of Application: (Pls. check)
New
Upgrading
Renewal
Others, pls. specify
_______________________

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AUTHORITY TO VERIFY FROM GOVERNMENT AGENCY/IES

PCAB
PCAB-PAD-UPG-F01
Revision
02
Eff. Date
6/22/2011
7 of
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AUTHORIZATION

The Philippine Contractors Accreditation Board (PCAB) is hereby authorized to

verify and secure information and/or copies of documents submitted by or in the name
of the firm to any or all of the following agencies relative to its application filed with the
PCAB:

1. Securities and Exchange Commission

2. Land Registration Authority
3. Land Transportation Office
4. Social Security System
5. Professional Regulation Commission

________________________
Signature over Printed Name
of Authorized Managing Officer

Date:_______________________

Type of Application: (Pls. check)

New
Upgrading
Renewal
Others, pls. specify
_______________________

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LIST OF CONSTRUCTORS REAL PROPERTIES

PCAB
PCAB-PAD-UPG-F01
Revision
02
Eff. Date
6/22/2011
8 of
Page

REAL PROPERTIES OF THE FIRM AS OF THE BALANCE SHEET DATE

COMPLETE
DESCRIPTION
(Type of land/building)

*TCTCLT/CCT/TD
NUMBER

LOCATION
(St. #, Barangay, Municipality/
City, Province)

ACQUISITION
COST

ACQUISITION
DATE

Residential

0042012006726

Lot 6 B-2 Real Street,

Matandang Balara, Quezon City

6,700,000.00

August 2012

Please reproduce if additional sheets are needed.

* TCT Transfer Certificate of Title

CCT Condominium Certificate of Title
TD Tax Declaration
CLT Certificate of Land Title

________________________
Type of Application: (Pls. check)
New
Upgrading
Renewal
Others, pls. specify
_______________________

Signature over Printed Name

of Authorized Managing Officer

Date:_______________________

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LIST OF CONSTRUCTORS PLANTS, VEHICLES AND

EQUIPMENT

PCAB
PCAB-PAD-UPG-F01
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02
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Page

A. DELIVERY AND TRANSPORTATION EQUIPMENT OF THE FIRM AS OF BALANCE SHEET

DATE
COMPLETE DESCRIPTION
Vehicle Brand / Type

Year
Plate No.
Model

Isuzu Dropside Truck w/ Boom

WKQ722

2001

Toyota Hilux Pick-up

AHA6856

2015

ACQUISITION
BOOK
VALUE
(in Php)

OR No. / Date

Date

Cost
(in Php)

000201342521009/
10/14/2013
000201572005989

02/20/2014

594,000

594,000

04/22/2015

1,300,000

1,300,000

Php1,894,000 Php1,894,000

OVER ALL TOTAL VALUE

Please reproduce if additional sheets are needed.

B. MACHINERIES/PLANTS AND OTHER CONSTRUCTION EQUIPMENT OF THE FIRM AS OF

BALANCE SHEET DATE
COMPLETE
DESCRIPTION
1 Kippor Generator Model KDE
6700
1 Robin Submersible Pump w/
Flexible Hose
1 Plate Compactor 13x19 w/ 5.0
HP Robin
1 Meiwa Walkbehind Roller
Model MFG-H4014
1 Bosch Demolition Hammer
Model GSH 27 VC 2000 watts
1 Show Ron Submersible Pump
1.0 HP Model SS 112-N

OVER ALL TOTAL VALUE

Type of Application: (Pls. check)

New
Upgrading
Renewal
Others, pls. specify
_______________________

ACQUISITION
Date

Cost
(in Php)

BOOK
VALUE
(in Php)

31313060706

02/14/2014

68,000

68,000

3232044

02/14/2014

17,800

17,800

5740657

03/10/2014

20,000

20,000

572064

03/17/2014

160,000

160,000

01000082

05/23/2014

85,000

85,000

S97 1962

7/30/2014

8,600

8,600

Php 359,400

Php 359,400

SERIAL NO.

By:_________________________
Signature over Printed Name
of Authorized Managing Officer
Date:________________

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LIST OF NOMINATED SUSTAINING TECHNICAL

EMPLOYEES

PRC REGISTRATION

NAME OF STE
Prof.

Date of
License
Number Registration Validity

PCAB
PCAB-PAD-UPG-F01
Revision
02
Eff. Date
6/22/2011
10
Page

Date
Position
Employed in the
Firm

Previously Nominated
1.Angelo P. Salazar

Civil
002657
Engineer
5

6/8/1982

11/2/2016

01/2013

2
3
4.
5.
6.
7.
8
9.
10.
11.
12.
13.
Newly Nominated
1.N/A
2.
3.
4.
5.
6.
7.
8
9.
10.

By:_________________________
Signature over Printed Name
of Authorized Managing Officer

Date:_______________________
Type of Application: (Pls. check)
New
Upgrading
Renewal
Others, pls. specify
_______________________

Operation
Manager

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SCHEDULES

PCAB
PCAB-PAD-UPG-F01
Revision
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Eff. Date
6/22/2011
11
Page

RECEIVABLES
To be accomplished if the applicant's receivable accounts (accounts/contracts & other receivable) exceed 50% of
the total networth/equity as of the latest audited balance sheet submitted in support of its application.
NAME OF PROJECTS

AMOUNT
DUE FOR
COLLECTION

AGE

CLIENT NAME COMPLETE ADDRESS

N/A

Please use additional sheets if necessary

Certified Correct by:

______________________________________
Printed Name and Signature of External Auditor

_____________________________
Printed Name and Signature of AMO

INVENTORIES
To be accomplished if the applicant's inventory accounts exceed 20% of the total networth/equity as of the latest
audited balance sheet submitted in support of its application.
Intended Use or
Age/Date
Physical
Types
Amount
Place of Storage
Purpose for
Acquired
Condition
Storing

N/A

Certified Correct by:

______________________________________
Printed Name and Signature of External Auditor

_____________________________
Printed Name and Signature of AMO

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SUSTAINING TECHNICAL EMPLOYEE AFFIDAVIT

Please accomplish this affidavit properly. Refer to the next page for STE qualification
requirements. )

PCAB
PCAB-PAD-UPG-F01
Revision
02
Eff. Date
6/22/2011
12
Page

Republic of the Philippines )

Province of _____________ )
City/Municipality of ________) S.S

I,
Born on

Passport size
Picture of STE

SURNAME

FIRSTNAME

Salazar

Angelo

DD

02

MM

11

YYYY

1959

Single / Married
to

MIDDLE NAME

Puruganan

SURNAME

Salazar

FIRSTNAME

MIDDLE NAME

Susan

Fortus

ST. # & NAME

BARANGAY
DISTRICT
CITY/MUNICIPAL
PROVINCE
and residing at:
14-C Real Street, New Intramuros Villlage, Matandang Balara, Quezon City, 1119
having duly sworn to in accordance with law depose and say:
1.
That I am a duly licensed
Civil Engineer
and holder of PRC License No.. 0026575
(PROFESSION)
valid up to ___November 2, 2016___.
That I hold a Bachelor's Degree in
2.
Given at:
3.

4.

COURSE / PROFESSION

BS Civil Engineering

NAME OF SCHOOL

Given on:

University of Santo Tomas

That my Tax Identification Number is :

And my Social Security System Number:
That I am employed on a regular and full-time
basis by:

INCLUSIVE DATES

June 1976 March 1981

118-356-902
33-5243686-6
NAME OF FIRM

SF Salazar Construction
POSITION IN THE FIRM

With position of

ZIPCODE

Operation Manager

as a STE for

CFY

2015-2016

5. That I am not presently employed by either a private company or any government office or government owned/controlled
corporation, nor a full time instructor, nor working abroad;
6. That I am not a holder of a valid contractor's license;
7. That I am not involved in any construction malperformance suggestive of negligence, incompetence or malpractice or any
act or omission liable for disciplinary action by myself or in collaboration with any other person;
8. That I have not been convicted by a court of competent jurisdiction of any offense involving moral turpitude;
9. That I am fully aware that my failure to notify the PCAB of my disassociation with my present employer shall cause my
disqualification to be a Sustaining Technical Employee or an Authorized Managing Officer or an applicant for a contractors
license with PCAB;
10. That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever sources PCAB may
consider appropriate;
11. That I am executing this affidavit to attest to the truth of the foregoing.
FURTHER AFFIANT SAYETH NAUGHT.

_______________________________
Affiant

SUBSCRIBED and sworn to before me this _____ day of ___________________, 20___ affiant exhibited his/her Community Tax Certificate No.
_____________ issued at ___________________ on ______________.
Doc. No.
Page No.
Book No.
Series of 20 ___

Notary Public
Until December 20 ___

PASTE

PASTE

PROF. I.D. CARD

PROF. I.D. CARD

VALID FOR

VALID FOR

CURRENT YEAR

CURRENT YEAR

Type of Application: (Pls. check)

(Front)
New
(photocopy)
Upgrading
Renewal
Others, pls. specify

(Back)
(photocopy)

QUALIFICATION REQUIREMENTS FOR STE

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PCAB
PCAB-PAD-UPG-F01
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02
Eff. Date
6/22/2011
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Page

1. A technology professional, such as engineer or architect, duly licensed by the Professional Regulation
Commission (PRC).
2. Holder of a valid PRC I.D.
3. With three (3) years minimum actual construction experience.
4. A full-time employee of the nominating contractor, not associated professionally or by employment with any
other party, particularly a party engaged in construction or construction-related activities.
5. Have none of the following disqualifications:
a) Involvement, in any capacity, in any construction malperformance of grave consequence, suggestive of
his negligence, incompetence and/or malpractice;
b) Involvement, by himself or in collaboration with any other person or firm, in any act or omission liable for
disciplinary action of which he/she is or the other person or firm was found guilty by the PCAB Board ;
c) Conviction by a court of competent jurisdiction of any offense involving moral turpitude; and
d) If formerly a Sustaining Technical Employee or an Authorized Managing Officer of any construction firm
but disassociated there from, failure to notify the Board of his disassociation in accordance with
paragraph 5 and 6 of the Affidavit of Undertaking.

This is to certify that I have verified with PRC the above stated professional eligibility/registration of the
Sustaining Technical Employee. Affiant herein and found the same to be true and correct.

__________________________________________
Signature over Printed Name of the AMO
Date: _______________________

Type of Application: (Pls. check)

New
Upgrading
Renewal
Others, pls. specify
_______________________

AFFIDAVIT OF STE CONSTRUCTION WORK EXPERIENCE

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PCAB
PCAB-PAD-UPG-F01
Revision
02
Eff. Date
6/22/2011
14
Page

Please use additional sheets if necessary

Republic of the Philippines )

Province of _____________ )
City/Municipality of ________) S.S
I, _________________________________, single/married, Filipino, of legal age, with postal address at
________________________________________________, having been duly sworn in accordance with law
depose and say that the projects enumerated below constitute my full & complete construction experience.
NAME and
COMPLETE ADDRESS of EMPLOYER/
NAME & LOCATION of PROJECTS
UNDERTAKEN

Work
Classification
(GE, GB,
SP)

PROJECT
DURATION
(mm/dd/yy)

Nature/Scope of Work
Assignment
(Proj. Engr.)

From

To

That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever sources
PCAB may consider appropriate;
That I am executing this affidavit to attest to the truth of the foregoing.
FURTHER AFFIANT SAYETH NAUGHT.
_________________________________
Affiant
SUBSCRIBED and sworn to before me this _____ day of _________________, 20__ affiant exhibited his/her
Community Tax Certificate No. ______________ issued at ____________________ on ____________________.
Doc. No ;
Page No.;
Book No.;
Series of 20 _______.

Notary Public
Until December 20 ___

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STE PERSONAL APPEARANCE

PCAB
PCAB-PAD-UPG-F01
Revision
02
Eff. Date
6/22/2011
15
Page

(TO BE ACCOMPLISHED BY THE STE)

NAME OF STE: SALAZAR

ANGELO

LAST NAME

PURUGANAN

FIRST NAME

Profession: Civil Engineer PRC ID No:

MIDDLE NAME

0026575

Expiration Date: November 2, 2016

Present Employer: SF SALAZAR CONSTRUCTION

I hereby confirm the following:
1. The veracity of the information reflected on the STE Affidavit and Affidavit of Construction
Experience that I executed in favor of the above present employer;
2. That I am fully aware that my failure to notify the PCAB of my disassociation from the
above-stated nominating firm and any misrepresentation in the attached forms shall cause
my disqualification as sustaining technical employee, or authorized managing officer, or a
licensee applicant with PCAB per Board Resolution No. 401, Series of 2001.
3. That I have been previously connected with the following companies and disassociated
therefore:
Previous Employers
Manila Water Company
Metropolitan Waterworks and Sewerage System

Date of
Employment

Date of
Resignation

08/1997
12/2012
03/198208/1997

Position

01/2013

Section Manager

07/1997

Supervising Engineer

4. Other Remarks:
_________________________________________________________________________________________
_________________________________________________________________________________________
Valid I.D.(s) Presented:
1. Drivers License

No: NO4-93-282187

2. Passport

No: EB2490350

________________________
STEs Signature
________________________
Date Signed

----------------------------------------------------------------------To be filled up by PCAB/DTI Personnel

____________________________
Signature over Printed Name
PCAB / DTI Office:_______________
Date :__________________________

STEs Specimen Signature (during interview):

____________________________

F
O
R
M

AFFIDAVIT OF REPRESENTATIVE

PCAB
PCAB-PAD-UPG-F01
Revision
02
Eff. Date
6/22/2011
16
Page

Republic of the Philippines)

Province of _____________ )
City/Municipality of ________) S.S
I, Susan F. Salazar, of legal age, Filipino, married/single with postal address at 14-C Real St.,
New Intramuros Village, Matandang Balara, Quezon City, after having been sworn to in accordance
with law, hereby depose and say:
1. That I am the Proprietor/Authorized Managing Officer (AMO) of
_________
____SF SALAZAR CONSTRUCION____
(Name of Firm)

______;

2. That I appoint ______Jill F. Salazar_____, whose picture and signature appear below, to
transact business with PCAB; i.e, present for pre-screening my application for contractors
license or any application related thereto, file/follow-up, submit documents, receive
notices/license in connection with the said application and the like.

Passport Size Photo

Most Recent
Taken within the last six
months prior to application
of PCAB license

Representative Signature over printed

Address: 14-C Real St., New Intramuros
Village, Matandang Balara, Quezon City

3. That I am aware that I am responsible/liable for any or all acts/representation made by my

representative in connection with the functions stated herein.
4. That I undertake to notify PCAB in the event that this appointment is modified, amended or
revoked.

______________________________________
AFFIANT
(Authorized Managing Officer of Firm)
SUBSCRIBED and sworn to before me this ______ day of ____________, 20___, affiant exhibited
his/her Community Tax Certificate No. _______________ issued at ___________ on
___________________.

NOTARY PUBLIC
Until December 20 ____

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