DOLEBWCIP3 Seriesof___________

RepublicofthePhilippines
ApplicationNo.______
DEPARTMENTOFLABORANDEMPLOYMENT
NationalCapitalRegion

RegistryofEstablishments

1a.BusinessName:________________________________________________________EIN
1b.RegisteredName:______________________________________________________
1c.TaxIdentificationNumber(TIN):___________________________________________

2.Address:_________________________________________________________________
Floor/Bldg.No./Street/SubdivisionBrgy./City/MunicipalityProvinceZipCodeGEOCODE

3.TelephoneNo. 4.FaxNo. 5.EmailAddress:

6.NameofManager/Owner

7.MainEconomicActivity:____________________________________________________PSIC
MajorProducts/GoodsorServices:___________________________________________Code

8.LegalOrg
anization(CheckAppropriateBox) 9.EconomicOrganization(CheckAppropriateBox)

SingleProprietorship SingleEstablishment
Partnership BranchOnly
GovernmentCorporation Establishmentandmainoffice
PrivateCorporation MainOfficeonly
Others.Specify_________________________ Ancillaryunit(exceptmainoffice)

10.TotalEmployment:_________Regular:____________NonRegular:_________
Male:____________AlienWorkers:______________Minors:Below15yearsold:___________
Female:__________16below18yearsold:________

11.TotalNumberofSubcontractors:____________________ 12.TotalNumberofSubcontractedEmployees:
___________

13.TechnicalInformation(Checkandenumerateaspossible)
Machinery,EquipmentandOtherDevicesinUse

CircularsawMachineDrillPressBoilerPressureVesselInternalCombustionEngine

EngineDieselGasolineOthers,specify_______________________
MaterialsHandlingEquipment

PowerTrucksHandTrucksConveyorsForkliftCranesOthers,specify_______

ChemicalorSubstancesUsedorHandled:___________________________________

ForUpdatingpurposes,accomplishalso:
14.IfnameofEstablishmenthasbeenchanged,stateformername:_____________________________________________
15.IflocationofEstablishmenthasbeenchanged,state formeraddress:__________________________________________

_______________________________________________________________

Floor/Bldg.No./Street/SubdivisionBrgy./City/MunicipalityProvinceZipCodeGEOCODE

CERTIFICATION

Thisistocertifyastotheaccuracyofthedataprovidedinthisform:
Name/SignatureofPersonAccomplishingtheForm:
Position: FaxNo.:
TelephoneNo.: EmailAddress:

DateFiled:____________________ DateApproved:____________ Approvedby: