JICA Form 2
(Please print on Company’s Letterhead)
SWORN STATEMENT ON COMPANY
BEING A NON-BLACKLISTED ENTITY
I,
(Name
of
Representative),
a
(Nationality)
citizen,
with
____________________________________________________________
accordance with law, hereby depose and state :
residential
and
postal
after having been duly
address
sworn to
at
in
That I am the (Position) of (Company Name) and that I hereby certify that (Company Name) is not blacklisted nor barred
from participating in the procurement procedures of the Government of the Philippines or any of its agencies, offices,
corporations or Local Government Units, including non-inclusion in the Consolidated Blacklisting Report issued by the
Government Procurement Policy Board once released in accordance with the guidelines to be issued by the GPPB as
provided in Section 69.4 of the IRR-A, and that at least 60% is owned by citizens of the Philippines.
IN WITNESS WHEREOF, I have hereunto affixed my signature on this ____ day of _________ 20__ at ______ City,
Philippines.
__(Signature of Representative)___
Name of Representative
Designation
SUBSCRIBED AND SWORN TO BEFORE ME this ______ day of __________, 20__ at _________________,
Philippines. Affiant exhibited to me his/her Residence Certificate / Passport No.__________________ issued at
____________, (Name of Country) on _______________.
_____________________
(Person Authorized by Law
To administer Oath)
Doc. No. ________
Page No.________
Book No.________
Series of________