PCAB-F-SVD-012. Revision 00.

Effectivity Date: 11/19/2018

APPLICATION FOR NEW LICENSE OF CONTRACTORS

APPLYING FOR AMNESTY

CHECKLIST OF REQUIREMENTS

In pursuance to Board Resolution No. 027, Series of 2019, hereunder are the requirements
to be submitted by applicants for a Contractor’s License with Category “Trade” and
Specialty-Trade under the Amnesty Program which shall be effective until 30 April 2019:

1. Letter – application for amnesty;

2. Properly accomplished license application form;

3. AMO Affidavit showing at least two (2) years managerial/technical experience in the
construction industry;

4. DTI/SEC Registration of business name (national in scope)

5. Registration with the SSS, PHILHEALTH AND PAG-IBIG

6. Complete Audited Financial Statements with accompanying Auditor’s Opinion Report

and Notes dated within the last six (6) months immediately preceding the filing of
application showing a Net Worth/Equity of at least P 100,000 (duly signed on each
and every page by an Independent CPA with valid PRC-BOA accreditation)

7. Original signature of Proprietor/AMO on each and every page of the application

forms including supporting documents;

8. Upfront payment of the P 10,000 additional license fee and other applicable fees.

Note:

Contractors who have not, as yet, completed the AMO Seminar, COSH and passed the
AMO Exam may avail of the Amnesty Program and file their respective applications,
provided that the same must be completed before the license is renewed.

Please see next page for Reminders (For Corporation/Partnership only)

Checklisted by:

_______________________________
PCAB / CIAP Window Staff /
DTI-ROG Staff

Enabling Business, Empowering Consumers

PHILIPPINE CONTRACTORS ACCREDITATION BOARD

5F, Executive Building Center, 369 Sen. Gil J. Puyat Ave., Makati City 1209, Philippines
Telephone: (632)895-4258 Telefax: (632)895-4220 E-mail: [email protected]
ciap.dti.gov.ph
 REMINDERS
(For Corporation/Partnership only)

1. If AMO is not the President, submit also the following:

a) Board Resolution on AMO’s duties and responsibilities:

(1) sign checks and other financial documents, (2) hire and fire
employees, (3) approve, negotiate and sign contracts, (4) commit
and answer for the corporation, (5) oversee all contracts of the
company;

b) Organizational Chart

2. SEC Registration should be accompanied by Articles of

Partnership/Incorporation (Construction Contracting should be one
of the purposes by which the corporation was formed)

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 .

Department of Trade & Industry Philippines

Construction Industry Authority of the Philippines
Philippine Contractors Accreditation Board
5th Floor, Executive Building Center,
369 Sen. Gil Puyat Ave.,
Makati City 1209

Subject : Application for Contractor’s License Under the Amnesty Program

Gentlemen:

I would like to apply for amnesty under PCAB Resolution No. 027, Series of 2019.

Pursuant to the requirements stated therein, I hereby submit the complete documents and
payment of the required licensing fees and the amount of P 10,000 Additional License Fee
under OR. No. ___ dated __ .

Thank you for your consideration.

Very truly yours,

.
Proprietor/AMO

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 AFFIDAVIT OF ATTESTATION

In behalf of
(Name of Firm)

holder of Contractor's License No. ___________, originally issued on _____________________________________,

I hereby request for Renewal of its Contractor's License for Contracting Fiscal Year 01 July 20 ____ to 30 June
20____.

I hereby request that its application for Contractor's License be approved.

I certify to the completeness of the information/documents contained in this application appertaining to

the category/classification the company is applying for and that the information/documents are true and
correct.

I further certify that the business name and/or SEC registration of this firm is valid and existing.

I certify furthermore that the SSS, Pag-IBIG, and PhilHealth contributions were remitted in favor of the
employees of this firm.

I am fully aware that:

1. All documents submitted in support to this application are subject to verification before PCAB action;

2. Any discovered misrepresentation of information and/or manifestations of fraud on the application

documents submitted by my firm applicant or its Authorized Representative/Agent/Liaison Officer shall be
subjected to investigation which may result to the disapproval of my application,
denial/suspension/revocation of license and blacklisting of my firm and myself as its Authorized Managing
Officer; and

3. Unconfirmed information/documents submitted to support my firm's qualifications shall be excluded for

categorization/classification purposes.

4. The evaluation of my qualification shall be solely based on the documents submitted at the time the
application was filed/accepted by PCAB.

Authorized Managing Officer (AMO)

(Signature over Printed Name)

Republic of the Philippines )

Province of _________________)
City/Municipality of ___________) S.S

SUBSCRIBED AND SWORN to before me this ________ day of ___________________ 20____ at

_____________________________________________; affiant exhibited to me his/her Community Tax Certificate
No. _______________ issued at ________________________________ on _________________________ 20 ___.

NOTARY PUBLIC
Until December 31, 20 ____

Doc. No.
Page No.
Book No.
Series of 20 __.

AMO must sign here:

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 PCAB INTEGRITY PLEDGE
We believe that the construction industry is one of the most susceptible to all forms of corruption that hampers the
noble objectives towards national progress and global competitiveness.

As frontrunners of nation-building, we acknowledge our major role and responsibility in ensuring that we carry out
our tasks guided by ethical standards and equipped with the necessary capability for the successful prosecution of
our contracts.

In view thereof, we pledge the following:

 We will present only true qualifications to PCAB so that we may be evaluated properly and be given the
category and classification where we should rightfully belong;

 We will uphold the dignity of the license and not be instruments for unlicensed contractors to undertake
construction projects through license lending nor through false joint ventures/consortium or pseudo
combinations which is inimical to the public safety/interest;

 We will not employ unlicensed sub-contractors/specialty contractors which is a clear circumvention of the
requirement that all contractors must be licensed;

 We will absolutely shun away from any form of collusion that destroys the very essence and integrity of
biddings;

 We will not engage in bribery or do any act which constitutes graft or corrupt practice which is the root
cause of bloated contract amounts;

 We will not use sub-standard materials which will in any way compromise the safety, reliability and
performance of the built environment;

 We will not abandon our contracts and we will implement our projects faithfully in accordance with the
prescribed specifications thereof;

 We will provide the necessary resources, financial and technical capability in carrying out our contractual
obligations, and as far as possible, within the stipulated time of completion;

 We are aware that we will be imposed disciplinary action should we violate any of the commitments hereof
or the PCAB Code of Ethics or be found to be a party to corruption.

ELOISA F. CORNEL
Authorized Managing Officer (AMO)
(Signature over Printed Name)
E. F. CORNEL ELECTRICAL SERVICES
Name of Company

Republic of the Philippines )

Province of _________________)
City/Municipality of ___________) S.S

SUBSCRIBED AND SWORN to before me this ________ day of ___________________ 20____ at

____________________________________________________________; affiant exhibited to me his/her
Community Tax Certificate No. _______________ issued at __________________ on _________________ 20 ___.

NOTARY PUBLIC
Until December 31, 20 ____

Doc. No.
Page No.
Book No.
Series of 20 __.

AMO must sign here:

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 CONTRACTOR’S GENERAL INFORMATION
Note: Please use additional sheets if necessary.
Name of Firm: (as per SEC or DTI)
E. F. CORNEL ELECTRICAL SERVICES
Office Address Telephone/Fax No. (include area code)
17 PAG-ASA ST., BRGY. HARAPIN ANG BUKAS, MANDALUYONG CITY (02) 369 9839

If Provincial based, contact address in Manila, if any

Website E-mail Address (required) Mobile No.

www.efces.com [email protected] +639176288216
Type of Firm (please check only one) Equity
[ x ] Sole Proprietorship [ ] Partnership [ ] Corporation Filipino: % Foreign: % Nationality: FILIPINO
International Organization for Standardization (ISO) Certification (please check, if any)
[ ] ISO 14001:2004 [ ] OSHAS 18001:2007 [ ] ISO 9001:2008 [ ] ISO 9001:2015
SEC / Business Name Registration No. Registration Date (mm/dd/yyyy) Expiry Date (mm/dd/yyyy)
05631822 11/21/2018 11/21/2023
Firm’s SSS No. Firm’s Tax Identification No. Firm’s PhilHealth No. Firm’s PAG-IBIG No.
80-0080998-6-000 445-514-790-000 002020003672 208809360006
Category Applied for Principal Classification Applied for Other Classification/s Applied for

TRADE TRADE N/A

2-day AMO Seminar

Participant Host/Organizer Inclusive Dates Venue

40-hour Safety Seminar ( [x ] COSH / [ x ] BOSH with Construction Safety Components )

Participant Company Position Course Provider Inclusive Dates Venue
Richville Hotel,
Eloisa F. Cornel Proprietor OHNAP January 25-30, 2016
Mandaluyong City
PEME
November 4, 11, 18, 25, PRESCON
Eloisa F. Cornel Proprietor Consultancy,
December 2, 2017 Philippines, Inc.
Inc.
Owners / Stockholders / Officers (for corporation / partnership)
PERCENTAGE
CAPITAL PAID-UP
NAME POSITION NATIONALITY SUBSCRIPTION CAPITAL Peso
Shares value

Directors / Officers (for corporation only)

NAME POSITION NATIONALITY ADDRESS

Certified correct by:

Authorized Managing Officer

(Signature over printed name)

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 AUTHORIZED MANAGING OFFICER (AMO) AFFIDAVIT
Note: Please accomplish this affidavit properly. Please use additional sheets if necessary.
1x1 Picture
Republic of the Philippines ) of AMO
Province of ______________)
City/Municipality of ________) S.S

Last Name First Name Ext. Name (Jr/Sr, if any) Middle Name
I,
CORNEL ELOISA FORTES
Citizenship mm dd yyyy Last Name First Name Middle Name
Born on 02 22 1992 Single N/A N/A N/A
FILIPINO
Room/Floor/Unit/Bldg. Name, Lot/Block/Phase No., Street, Subdivision, Barangay, City/Municipality, Province, Zip Code
and
residing at:
17 PAG-ASA ST., BRGY. HARAPIN ANG BUKAS, MANDALUYONG CITY
having duly sworn to in accordance with law depose and say:
1. That I am the Authorized Managing Officer of :
E. F. CORNEL ELECTRICAL SERVICES
(Name of Firm)
with position of:
PROPRIETOR
(Position in the Firm)
2. That I possess the following educational attainments (attach additional sheet if necessary)
Name of School Address Course Inclusive Dates
DON QUIJOTE ST., SAMPALOC BACHELOR OF SCIENCE IN
ST. JUDE COLLEGE - MANILA JUNE 2008 – MAY 2012
MANILA NURSING

3. That I possess at least two (2) years experience in the construction industry as follows (Ref. Sec. 20 of IRR of R.A. 4566)
Dates of
Designation / Position Company / Nature of Business Address Job Description
Employment
NEW GOLDEN CITY BUILDERS
SEPT. 2016 –
COMPANY NURSE & DEV’T CORP. / GENERAL PACO, MANILA NURSE/SAFETY
MAY 2017
CONSTRUCTION
PRESCON PHILS. INC. / GEN.
JUNE 2017 –
COMPANY NURSE CONSTRUCTION & POST MANDALUYONG NURSE/SAFETY
SEPT. 2018
TENSIONING
PIONEER SPECIALTY
OCT. 2018 –
COMPANY NURSE BUILDING SYTEMS INC. / QUEZON CITY NURSE/SAFETY
FEB. 2019
CONSTRUCTION
4. That I possess knowledge of the building, safety, health, & lien laws of the Republic of the Philippines & the rudimentary
administrative principles of construction contracting from my work experiences in item 3 above and from the following
training/seminars (Ref. Sec. 20 of IRR of R.A. 4566):
5. That I am not involved in any construction malperformance suggestive of negligence, incompetence or malpractice or any act of
omission liable for disciplinary action by myself or in collaboration with any other person (Section 4.2 of IRR of R.A. 4566)
6. That I have not been convicted by a court of competent jurisdiction of any offense involving moral turpitude (Section 4.2 of IRR
of R.A. 4566)
7. That I am fully aware that my failure to notify PCAB of my disassociation with my present employer shall cause my
disqualification to be an Authorized Managing Officer, a Sustaining Technical Employee or a license applicant with PCAB .
8. That I authorize the PCAB to verify and investigate any or all information in this instrument from whatever sources PCAB may
consider appropriate
9. That I certify under pain of perjury that all information on this affidavit are true and correct.
FURTHER AFFIANT SAYETH NAUGHT.
_______________________________
Authorized Managing Officer (AMO)
(Signature over Printed Name)

SUBSCRIBED AND SWORN to before me this _____ day of __________________________________________________ 20___

at ___________________________________________________________________________; affiant exhibited his/her Community
Tax Certificate No. _____________ issued at _________________________________________ on ______________ 20________.

NOTARY PUBLIC
Until December 31, 20 ___
Doc. No.
Page No.
Book No.
AMO must sign here:

6
 CORPORATE SECRETARY’S CERTIFICATION
Note: For Corporation/Partnership only.

Republic of the Philippines )

Province of ______________)
City/Municipality of ________) S.S

Last Name First Name Ext. Name (Jr/Sr, if any) Middle Name
I,
Room/Floor/Unit/Bldg. Name, Lot/Block/Phase No., Street, Subdivision, Barangay, City/Municipality, Province, Zip Code
and residing
at:

do hereby certify, in my capacity as the duly elected and incumbent Corporate Secretary of

______________________________________________________________________________________________
(Name of Firm)
mm dd yyyy City / Municipality of Meeting
That during its regular meeting held on held at

Wherein a quorum was present , the following resolution was unanimously approved, to wit:

AMO NOMINATION

"R E S O L V E as it is hereby resolved that

___________________________________________________________________,
(FIRSTNAME MIDDLENAME SURNAME)

a senior executive who has been granted the power to render general management and
administrative decision, be appointed as the firm's Authorized Managing Officer to act on all
matters concerning the requirements of the PCAB and implementation of R.A. 4566 as amended
by P.D. 1746."

IN WITNESS WHEREOF, I have hereunto affixed my hand this ___________ day of ___________________ 20___, in
______________________________, Philippines.

____________________________
Corporate Secretary
(Signature over Printed Name)

SUBSCRIBED AND SWORN to before me this ______ day of ______________________________________ 20___

at _____________________________________________________; affiant exhibited his/her Community Tax
Certificate No. ________________ issued at _________________________________ on ______________ 20______.

NOTARY PUBLIC
Until December 31, 20 ___

Doc. No.
Page No.
Book No.
Series of 20 ___

AMO must sign here:

7
 AUTHORITY TO VERIFY DOCUMENTS WITH DEPOSITORY BANK

THE MANAGER
BPI FAMILY SAVINGS BANK
KALENTONG BRANCH
792-E Gen. Kalentong Cor Pag-Asa St.
Mandaluyong City 1550

Subject: Bank Account Number C/A 5035-0540-83

Sir:

Please provide the Philippine Contractors Accreditation Board (PCAB), a government agency under the
Department of Trade and Industry, any information they need regarding the subject account with your bank.

I am applying for a contractor's license from PCAB and part of their evaluation process is the verification of
bank deposits and other assets of an applicant.

This will serve as your authorization to release any information that may be requested by PCAB regarding the
above subject account.

Thank you.

Very truly yours,

Name of Firm:
E. F. CORNEL ELECTRICAL SERVICES

By: ELOISA F. CORNEL

Authorized Managing Officer (AMO) or
Authorized Signatory with the Bank
(Signature over Printed Name)

Date:_______________________

AMO must sign here:

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 AUTHORITY TO VERIFY DOCUMENTS WITH GOVERNMENT AGENCIES

The Philippine Contractors Accreditation Board (PCAB) is hereby authorized to verify and secure
information and/or copies of documents submitted by or in the name of the firm to any or all of the following
agencies relative to its application filed with the PCAB:

1. Securities and Exchange Commission (SEC)

2. Land Registration Authority (LRA)

3. Land Transportation Office (LTO)

4. Social Security System (SSS)

5. Professional Regulation Commission (PRC)

6. Philippine Health Insurance Corporation (PhilHealth)

7. Home Development Mutual Fund (Pag-IBIG)

ELOISA F. CORNEL
Authorized Managing Officer (AMO)
(Signature over Printed Name)

Date:______________________

AMO must sign here:

9
 AUTHORIZED REPRESENTATIVES AFFIDAVIT
Note: To be accomplished by the AMO.

Republic of the Philippines )

Province of ______________)
City/Municipality of ________) S.S
Last Name First Name Ext. Name (Jr/Sr, if any) Middle Name
I, CORNEL ELOISA FORTES
mm dd yyyy Last Name First Name Middle Name
born on Single N/A N/A N/A
02 22 1992
and Room/Floor/Unit/Bldg. Name, Lot/Block/Phase No., Street, Subdivision, Barangay, City/Municipality, Province, Zip Code
residing
at: 17 PAG-ASA ST., BRGY. HARAPIN ANG BUKAS, MANDALUYONG CITY
having duly sworn to in accordance with law depose and say:
That I am the Name of Firm
Authorized
Managing E. F. CORNEL ELECTRICAL SERVICES
1. Officer of :
Room/Floor/Unit/Bldg. Name, Lot/Block/Ph. No., Street, Subdivision, Barangay, City/Municipality, Province, Zip Code
with office
address at: 17 PAG-ASA ST., BRGY. HARAPIN ANG BUKAS, MANDALUYONG CITY
That I appoint two (2) representatives, whose pictures and signatures appear below:
Name of Representatives and Signature of Representatives
Pictures (2x2) of Representatives
Positions in the Firm over Printed Name
Representative 1 Representative 1 Representative 1

ANGELO W. PURA
Account Manager ANGELO W. PURA

2.
Representative 2 Representative 2 Representative 2

to transact business with PCAB; i.e, present for pre-screening my application for contractor’s license or any
application related thereto, file/follow-up, submit documents, receive notices/license in connection with the said
application and the like.
That I am aware that I am responsible/liable for any or all acts/representation made by my representatives in
3.
connection with the functions stated herein.
4. That I undertake to notify PCAB in the event that this appointment is modified, amended or revoked.
That I have read and fully understood and complied with the requirements of PCAB Board Resolution No. 515 s.
5.
2011 (copies of required documents are attached).

ELOISA F. CORNEL
Authorized Managing Officer (AMO)
(Signature over Printed Name)

SUBSCRIBED AND SWORN to before me this _________ day of ____________________________, 20_____ at

_____________________________________________________; affiant exhibited his/her Community Tax Certificate
No. _____________________ issued at _____________________________ on ________________ 20_________.

NOTARY PUBLIC
Until December 31, 20 ___
Doc. No.
Page No.
Book No.
Series of 20 ___

AMO must sign here:

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