PREQUALIFICATION FORM For CI

ENGINEERING OFFICE
CHECKLIST FOR PRE-QUALIFICATION
Name of Contractor : _________________________

Date : _________________________
Submitted Remarks
1 Contractor's Prequalification Statement
2 Contractor's General Information Sheet
3 Contractor's Legal Aspects Information Sheet
4 Contractor's Technical Aspects Information Sheet
5 Contractor's Present Organizational Chart
6 Contractor's Financial Aspects Information Sheet
7 Auditor’s or Accounts Certificate on Financial Statement
Checked by: _________________________
Noted by: _________________________
Conforme: _________________________
Contractor
CONTRACTOR’S CONFIDENTIAL
PREQUALIFICATION STATEMENT
I, ___________________________ of legal age, with address of

____________________________________ after having been sworn in accordance
with law hereby dispose and say:
1. That I am the ___________________ of the ____________________,

(Designation) (Name of Contractor)
duly authorized to make this statement, evidenced by the attached written
authority from the owner(s) / Governing Board of Contractor (Annex 1).
2. That I hereby present the following information in response to the invitation for
application for Phase 1 Prequalification of Contractors for Hotel Sogo,
Eurotel, Icon Hotels ____________________.
a. SSS Certificate
b. SEC Certificate
c. DOLE Certificate
d. Updated Business Permit
e. DTI Certificate
f. BIR Registration
g. PCAB Certificate
AFFIDAVIT
I hereby certify that all information in this Phase 1 Prequalification Statement,

including the annexes and enclosures thereto, are true and correct, and I hold myself
liable, criminally or civilly, for any misrepresentation or false statement made therein,
and grounds for disqualifications and termination of accreditation.
In faith whereof, I have hereto affixed my signature this ___ day of ________,
20__ at ________________, affiant issued on _______________.
_________________
Affiant _______________________
Notary Public
Until________________, 20___
PTR No.___________________
Date______________________
Place _____________________
TAN ______________________
Doc No.__________________
Pages No.________________
Book No._________________
Series of _________________
AUDITOR’S OR ACCOUNTANT’S CERTIFICATE
To Whom It May Concern:
I / We certify that I / we have examined the books and accounts of:

___________________________, _______________________________________
(Name of Contractor) (Business Address)
an individual proprietorship / partnership / association / corporation have prepared the
foregoing Financial Statement; and have verified the items appearing therein in
accordance with the approved accounting and auditing standards; and, in my / our
opinion, the foregoing Financial Statement fairly reflects the true condition of the
aforesaid contractor as of the date stated above.
.
Date ______________________ ____________________________
(Date of Certificate) (Name and Signature)
Certified Public Accountant

Registration No. ______________
License No.__________________
Dates Effective _______________
From _______________________
To __________________________
Place ______________________________
(Accountant’s Office Address)
GENERAL INFORMATION
1. Name of Contractor ________________________________________
2. a. Home/ Office Address ________________________________________

________________________________________
b. Telephone No. ________________________________________
c. Cable Address ________________________________________
d. Telex No. ________________________________________
3. a. In the case of a foreign contractor, Philippine address, if any:

_____________________________________________________________
b. Telephone No. ________________________________________
4. Type of Contractor’s Organization (Please Check):

( ) Sole Proprietorship ( ) Corporation
( ) Partnership ( ) Joint Venture
5. a. Person Managing the affairs of Contractor’s Organization ______________

b. Designation _____________________________________________
c. Certified Copy of his appointment / designation and authority (Annex 2).
6. Type of trade for which the contractor wishes to pre-qualify (Please Check)
( ) Structural ( ) Auxiliary
( ) Civil Works ( ) Fire Protection
( ) Electrical ( ) Architectural
( ) Sanitary ( ) Interior Design
( ) Mechanical ( ) Others (Pls. specify)
LEGAL ASPECTS
1. Date Contractor’s organization had been organized ____________________

2. Place of registration _____________________________________________
3. Certified Copy of Contractor’s License for the current year (Annex 3)
4. Certified Copy of Contractor’s latest privilege tax receipt PTR (Annex 4)
5. If Contractor is a Sole Proprietorship
a. Certified Copy of Certificate of Registration (Annex 5)
b. Name of Owner ______________________________________________
6. If Contractor is a Partnership
a. Certified copy of Deed or Articles of Partnership (Annex6)
b. Partners:
Name Value of Contribution

_________________________ _____________________________
_________________________ _____________________________
_________________________ _____________________________
_________________________ _____________________________
_________________________ _____________________________
7. If the Contractor is a Corporation

a. Certified Copy of Articles of Incorporation (Annex 7)
b. Stockholders and others financially interested in the corporation owning 5%
or more of the stocks and other interest, as certified by the Securities and
Exchange Commission.
Types of Stocks
Name and/or Interest Value Extent of Financial Control
_______________ _____________ ____________ _____________________
_______________ _____________ ____________ _____________________
_______________ _____________ ____________ _____________________
_______________ _____________ ____________ _____________________
_______________ _____________ ____________ _____________________
c. Members of the Governing Board of the Corporation, as Certified by Corporate

Secretary.
Name Designation
_________________________ _____________________________
_________________________ _____________________________
_________________________ _____________________________
_________________________ _____________________________
_________________________ _____________________________
8. If Contractor is a Joint Venture:

a. Certified Copy of Agreement and Articles of Joint Venture (Annex 8)
b. Certified Copy of a Joint Venture License per Republic Act No. 4566 (Annex 9)
c. Contractor – members of Joint Venture
Name Designation
_________________________ _____________________________
_________________________ _____________________________
_________________________ _____________________________
_________________________ _____________________________
_________________________ _____________________________
9. In the case of a foreign Contractor, Certificate as bonafide contractor from its

embassy or consulate (Annex 10).
10. Extent of Filipino ownership of the assets of Contractor’s Organization.

LIABILITIES AND NETWORTH
LIABILITIES
(1) Notes Payable:

(a) To Banks “for regular conduct of business” P___________
(b) To Banks “for Certified Checks” ___________
(c) To others “for regular conduct of Business” ___________
(d) To others “for Equipment” ___________
(e) To others “for Sundry Purposes” ___________
(2) Accounts Payable
Net Due Past Due

(a) Business ____________________ __________________
(b) Other ____________________ __________________
(3) Accrued Liabilities (Itemize below)

(a) _____________________________________________________
(b) _____________________________________________________
(4) Long-Term Obligation (Itemize below and indicate assets pledged as Security)
(a) _____________________ _____________________ _________________
(b) _____________________ _____________________ _________________
(5) Other Liabilities (Itemize below)

(a) _____________________ _____________________ _________________
(b) _____________________ _____________________ _________________
(6) Reserves – Other than Depreciation

(a) _____________________ _____________________ _________________
(b) _____________________ _____________________ _________________
TOTAL LIABILITIES P_________________

NET WORTH
If Proprietor or Partnership Proprietor or Partners

______________________________ _____________________________
______________________________ _____________________________
______________________________ _____________________________
______________________________ _____________________________
______________________________ _____________________________
Less: Personal Drawings _____________________________

Total _____________________________
Add: Net Income for the Period _____________________________
TOTAL NET WORTH __________________
If Corporation or Joint Venture

(a) Capital Stock:
Preferred (describe fully)
__________________________________ P_________________
__________________________________ _________________
__________________________________ _________________
Total
Add: Paid-in Surplus (if any)
Total Capital Stock Paid-up P_________________
(b) Surplus
Appropriated (Itemize below)
1. ________________________________ _________________
2. ________________________________ _________________
3. ________________________________ _________________
4. ________________________________ _________________
Appraisal Surplus if any________________
TOTAL NET WORTH __________________
TOTAL LIABILITIES AND NET WORTH __________________

PROJECT NAME:
OWNER:
CONTACT PERSON/NUMBER:
LOCATION:
DATE STARTED:
DATE FINISHED:
PROJECT COST:
SCOPE OF WORK:
SSS CERTIFICATE
SEC(if any)
DTI CERT.
DOLE CERT.(if any)
BUSINESS PERMIT 2013
PCAB CERT.(if any)
BIR CERT.
Please include
UPDATED RESUMES (President, Gen.Manager, etc)
TOOLS & EQUIPMENTS CHECKLIST (QTYS)
SEPARATE ON GOING TO COMPLETED PROJECTS

PREQUALIFICATION FORM For CI

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ENGINEERING OFFICE

CHECKLIST FOR PRE-QUALIFICATION

Name of Contractor : _________________________

1 Contractor's Prequalification Statement

2 Contractor's General Information Sheet

3 Contractor's Legal Aspects Information Sheet

4 Contractor's Technical Aspects Information Sheet

5 Contractor's Present Organizational Chart

6 Contractor's Financial Aspects Information Sheet

7 Auditor’s or Accounts Certificate on Financial Statement

Checked by: _________________________

Noted by: _________________________

I, ___________________________ of legal age, with address of

1. That I am the ___________________ of the ____________________,

I hereby certify that all information in this Phase 1 Prequalification Statement,

To Whom It May Concern:

I / We certify that I / we have examined the books and accounts of:

Certified Public Accountant

1. Name of Contractor ________________________________________

2. a. Home/ Office Address ________________________________________

3. a. In the case of a foreign contractor, Philippine address, if any:

4. Type of Contractor’s Organization (Please Check):

5. a. Person Managing the affairs of Contractor’s Organization ______________

1. Date Contractor’s organization had been organized ____________________

Name Value of Contribution

7. If the Contractor is a Corporation

c. Members of the Governing Board of the Corporation, as Certified by Corporate

8. If Contractor is a Joint Venture:

9. In the case of a foreign Contractor, Certificate as bonafide contractor from its

10. Extent of Filipino ownership of the assets of Contractor’s Organization.

(1) Notes Payable:

(2) Accounts Payable

Net Due Past Due

(3) Accrued Liabilities (Itemize below)

(5) Other Liabilities (Itemize below)

(6) Reserves – Other than Depreciation

TOTAL LIABILITIES P_________________

If Proprietor or Partnership Proprietor or Partners

Less: Personal Drawings _____________________________

TOTAL NET WORTH __________________

If Corporation or Joint Venture

Appraisal Surplus if any________________

TOTAL NET WORTH __________________

TOTAL LIABILITIES AND NET WORTH __________________

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1. That I am the _ of the __,