PHILIPPINE BUSINESS REGISTRY SEC-REGISTERED COMPANIES APPLICATION FORMA. SEC REGISTRATION INFORMATION 1. Business Type Stock Corporation General Partnership Foreign Non-Stock Corp (Please select one.) Non-Stock Corporation Limited Partnership Foreign Partnership Foreign Stock Corporation Professional Partnership 2. SEC Registration No. 3. SEC Registration Date 4. TIN (pre-generated issued by SEC) 5. Company Name B. BUSINESS DETAILS 6. House/Building No. 7. 8. 9. House/Building Name Street Barangay 10. Town/City 11. Province 13. Phone No. (Please put in area code) 15. Mobile No. C. PSIC and Other Details 17. Business Activities (Please check all that applies) 18. Main Business Activity (Select one among the business activities you chose above) 19. Indicate Main Product Handled/ Service Rendered 20. Total No. of Employees 14. Fax. No. (Please put in area code) 16. eMail Address 12. Region Manufacturer/Producer Importer Manufacturer/Producer Importer Service Retailer Wholesaler Retailer Wholesaler Exporter Service Exporter D. DOING BUSINESS AS (List down company names and please use another form if more than 5 ) E. INCORPORATOR/PARTNER DETAILS (At least 2 is required. If more than 2 incorporators, use another application form) MAIN INCORPORATOR/PARTNER 21. Position/Title: 22. First Name: 24. Last Name: 26. SSS Number: 28. TIN: 29. House/Building No. Page 1 of 2 23. Middle name: 25. Suffix: 27. Pag-ibig Number: Telefax Number: 56. Barangay 47. Barangay 33. Street 32. Province PARTNER/OTHER INCORPORATOR 36. Mobile Number: _________________________________ OWNER’S Signature over Printed Name For DTI/SEC-PBR Kiosk Use Only TRN/ PBN Date Registered BN Certificate No. SSS Number 65. Suffix: 63. First Name: 38. Last Name: 40. Middle name: 39. Page 2 of 2 . PAG-IBIG Employer No. First Name: 52. Email Address: Representatives Details 58. Last Name: 54. Street 46. SSS Employer No. SSS Number 57. Telefax Number: 64. Suffix: 41. use another application form) Representatives Details 50. Email Address: 59. PhilHealth Employer No. Region 37. Pag-ibig Number: 35. SSS Number: 42. Town/City 48. 44. Middle Name: 61. Mobile Number: 51. Province 49. House/Building No. Town/City 34. AUTHORIZED REPRESENTATIVES (At least 1 is required. TIN: 43. Last Name: 62. Suffix: 55. Office ________________________ Date Fee: OR Number: Rec’d by: Date Paid: BIR Tax Identification No. House/Building Name 31. House/Building Name 45. If more than 2 representatives. Middle Name: 53. First Name: 60. Region F.30.