DOLEBWCIP3 Seriesof___________ ApplicationNo.______RepublicofthePhilippines

DEPARTMENTOFLABORANDEMPLOYMENTNationalCapitalRegion

RegistryofEstablishments

1a.BusinessName:________________________________________________________EIN1b.RegisteredName:______________________________________________________1c.TaxIdentificationNumber(TIN):___________________________________________2.Address:_________________________________________________________________Floor/Bldg.No./Street/SubdivisionBrgy./City/MunicipalityProvinceZipCodeGEOCODE

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

6.NameofManager/Owner

7.MainEconomicActivity:____________________________________________________PSICMajorProducts/GoodsorServices:___________________________________________Code

8.LegalOrg anization(CheckAppropriateBox)

SingleProprietorshipPartnershipGovernmentCorporationPrivateCorporationOthers.Specify_________________________

9.EconomicOrganization(CheckAppropriateBox)SingleEstablishmentBranchOnlyEstablishmentandmainofficeMainOfficeonlyAncillaryunit(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

CERTIFICATIONThisistocertifyastotheaccuracyofthedataprovidedinthisform:Name/SignatureofPersonAccomplishingtheForm:Position: FaxNo.:TelephoneNo.: EmailAddress:DateFiled:____________________

DateApproved:____________ Approvedby: