JICA Form 1 (1/5)
Applicant No. ___
APPLICATION FORM FOR JICA SUPPLIER REGISTRATION
1. Business Information * indicates a required section/ field
Registered Business/ Trade / Company Name
Business/ Mailing Address (attach location sketch)
(P.O. Box not allowed)
Main office:
Street address:
City:
Province/ Region:
Zip/ Postal Code:
Branches:
Street address:
City:
Province/ Region:
Zip/ Postal Code:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
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Contact Numbers
Telephone Number(s):
Fax Number:
Mobile Number:
______________________________
______________________________
______________________________
Email address:
______________________________
Web site:
______________________________
2. General Information*
a. General Business Information
SEC/DTI/CDA Business Registration Number and Date
Year Business was Established
Form of Ownership
□ Single Proprietorship
□ Foundation
□ Partnership
□ Corporation
Others (specify)
______________________
Capitalization 1
Authorized Capital __________
Subscribed Capital __________
Paid up Capital __________
Type of Supplier as registered with SEC or DTI
□ Manufacturer □ Retailer
□ Producer
□ Exporter
□ Service
□ Importer
□ Wholesaler
□ Exclusive Distributor
□ Trading House/ Company
_________ srehtO(specify)
BIR TIN Number
BIR VAT Registration Number
The information is reflected in the Supplier’s SEC Registration Papers/ Articles of Incorporation or the DTI Business Registration
Papers.
1
JICA Form 1 (2/5)
b. Primary Contact Information *
Name of Officers:
President
Secretary
Treasurer
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_____________________________________
_____________________________________
Name of Authorized Representative
Official Title/ Position
Telephone number
Mobile number
Fax number
Email Address
_____________________________________
_____________________________________
_____________________________________
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Current Number of Full time Employees
Type of Employees
No. Of
employees
Management
Administrative
Sales
Technical/ Operations
Others, specify
Total
Principal Products/ Services
(Please refer to Attachment 1. Please use additional
sheets if necessary)
Products/Services
Names and addresses of parent company,
subsidiaries or associated companies with whom
there is collaboration or joint venture, if any:
Name of Company
________________________________________
________________________________________
_________________________________________
Address
______________________________________________
______________________________________________
3.Financial Information *
Most Recent Financial Year
(e.g. 2010)
Prior Financial Year
(e.g. 2009)
Net worth or Total Stockholder’s Equity
Net Sales
4. References and Transaction Record
(Please indicate names, address, telephone/ fax numbers, email address and contact persons; references may be
contacted by JICA Philippine Office)
Name of Bank (s) &
Address
Contact Name
Telephone no. &
Fax No
Email Address
JICA Form 1 (3/5)
I do hereby certify that I have the authority to prepare and submit this supplier registration and at the information provided
is true and correct. I hereby acknowledge that the JICA Philippine Office Terms and Conditions will be used as basis for
any and all contracts.
____________________________________________________
Signature
____________________________________________________
Name
____________________________________________________
Official Designation
Date: _______________________________________________
Attachment to JICA Form 1 (4/5)
Instruction to Supplier Applicant:
Please specify major business activity (ies) and products/ goods being offered by your company.
Name of Supplier Applicant: __________________________________________________________
Business Activity
Agriculture
Products/ Goods
Agricultural Machinery & equipment
Agricultural Products
Agricultural services
Construction
Construction of buildings, etc.
Construction of roads, bridges, etc.
Construction materials
Construction services
Cultural & recreation services
Arts
Parks
Gardens
Services to the arts
Books
Books
Maps
Other Publications
Sports & recreation
Sports products
Equipment
Services
Dental supplies & equipment
Dental supplies
Dental equipment
Electricity, Gas and Water
Electricity
Gas
Water supply
Sewerage services
Drainage services
Chemicals & Chemical Products
Electronics
Computers
Computer accessories
Computer components
Computer Input Devices
Computer software
Business & productivity
Communications
Developer Tools
Graphics & publishing
Operating systems
Reference
Utilities
Computer Storage Devices & Media
Computer Systems
Control and Instrumentation Instruments/
equipment
Attachment to JICA Form 1 (5/5)
Business Activity
Products/ Goods
Electronics (continuation)
Electrical Supplies/Accessories
Automotive Electronics
Fire fighting, rescue & safety equipment
Office Furniture and Fixtures
Office devices & supplies
Information & Communications Technology
Information Technology Services & IT enabled
services
Information Technology Parts, Accessories &
Peripherals
Janitorial equipment & supplies
Maritime/ Navigational & Railway Equipment
Medical Supplies, Laboratory Instruments &
Medical Equipment
Medical Supplies
Laboratory Instruments
Medical Equipment
Mining and Quarrying
Mining
Extraction
Exploration
Coal
Oil
Gas
Metallic
Non - Metallic
Quarrying
Pharmaceuticals
Telecommunications.
radar
Communications
and
Communications & communication services
Cellular phones, cards, accessories
Internet service providers
Postal services
Courier services
Telecommunications services
Transport & storage services
Transport
Air
Road
Water
Rail
Storage
Vehicles, vehicle
components
parts,
accessories
&
Vehicles
Vehicle parts, accessories & components
Vehicle repairs & services
Wholesale & retail trading
Wholesale Trading
Retail Trading
Water treatment, equipment & products