Scribd
Upload
236 views

Notarized - Application Form

This document is an application for a PEZA Visa from Fred Kumetz, a Mexican national. [1] He provides personal details like his name, age, nationality, passport information, Philippine address and contact details. [2] He is employed as the President of eData Services Phils. Inc, a PEZA-registered enterprise located in Taguig City. [3] The application includes requirements like endorsements, proof of payment, documents establishing his employment and position, and guarantees from the employing enterprise regarding responsibilities if his employment ends.

Uploaded by

John Michael Gatpayat
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
236 views

Notarized - Application Form

This document is an application for a PEZA Visa from Fred Kumetz, a Mexican national. [1] He provides personal details like his name, age, nationality, passport information, Philippine address and contact details. [2] He is employed as the President of eData Services Phils. Inc, a PEZA-registered enterprise located in Taguig City. [3] The application includes requirements like endorsements, proof of payment, documents establishing his employment and position, and guarantees from the employing enterprise regarding responsibilities if his employment ends.

Uploaded by

John Michael Gatpayat
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

LAG.2.F.

004
Rev. 01: 02 May 2022

Republic of the Philippines


PHILIPPINE ECONOMIC ZONE AUTHORITY
DoubleDragon Center West Building
DD Meridian Park, Macapagal Avenue, Pasay City
Trunk Line No.: (632) 8551-3451 Loc. 111/112/117 | Direct Line No.: (632) 8551-3427 | E-mail Add:
[email protected]

APPLICATION FOR PEZA VISA (PV)


The undersigned hereby requests for issuance of a PEZA Visa (PV) with special multiple entry
privileges and with exemptions from exit clearances certificates, re-entry permits and special
return certificates, pursuant to Memorandum of Agreement between Philippine Economic Zone
Authority (PEZA) and Bureau of Immigration (BI), and in support thereof submits the following
information and representation.

FRED JACK KUMETZ


FIRST NAME MIDDLE NAME LAST NAME

73
Age: _________ MALE
Sex: _________ OCT. 3, 1948
Date of Birth: ___________ MEXICO CITY
Place of Birth: ______________
MEXICAN
Nationality _______________ MARRIED
Civil Status (Single, Married, Divorced, etc.): _____________
N00245400
Passport No. ________________________ LOS ANGELES
Issued at: ______________________________
Issued on: DEC. 16, 2021
________________________ DEC. 16, 2031
Valid until: _____________________________
c/o UNIT 3401 FORBES TOWER CONDOMINIUM, VALERO ST.,
SALCEDO VILLAGE, MAKATI CITY
Philippine Residential Address:____________________________________________________
0917-8268888
Telephone: ______________

eDATA SERVICES PHILS., INC.


Employing PEZA-registered enterprise: _____________________________________________
11/F UNIT A, TEN WEST CAMPUS BLDG., 20 LE GRAND AVE., MCKINLEY WEST, FORT BONIFACIO, TAGUIG CITY
Enterprise Address: _____________________________________________________________
PRESIDENT
Position: ______________________ 8884-1567/1568
Tel No.: __________ [email protected]
E-mail Address: _______________

Date of Arrival and Length of Stay (for new application): _________________________________


JURIS DOCTOR DEGREE,SOUTHWESTERN
Educational Background, Training and Experience: ____________________________________
UNIVERSITY SCHOOL OF LAW L.A., CALIFORNIA; ADJUNCT PROFESSOR OF LAW;
_____________________________________________________________________________
ATTORNEY FOR THE MEXICAN CONSULATE IN L.A. CALIFORNIA
_____________________________________________________________________________

DEPENDENTS APPLYING FOR VISA WITH THE PRINCIPAL IN THE PHILIPPINES:


Spouse: Name: ____________________________ Age: ____ Sex: ___ Date of Birth: __________
Passport No: _______________ Nationality: ____________

Children: Name: ____________________________ Age: ____ Sex: ___ Date of Birth: _________
Passport No: _______________ Nationality: ____________

Name: ____________________________ Age: ____ Sex: ___ Date of Birth: _________


Passport No: _______________ Nationality: ____________

UNDERTAKING OF PEZA REGISTERED ENTERPRISE:

a) Within five (5) working days from termination or cessation of employment for whatever cause,
the PEZA-registered enterprise shall inform PEZA in writing of such termination or cessation of
employment and when applicable, within the same period, shall surrender the work permit and/or
ACR I-Card.

b) PEZA-registered enterprise shall likewise assume responsibility for the voluntary departure
and cancellation of PEZA visa of said Foreign National upon termination of employment/training.

DOCUMENTARY REQUIREMENTS:

 PEZA ZA/ZM Endorsement to the Director General


 Copy of PEZA Official Receipt issued for payment of the Processing Fee duly certified as true
copy by the PEZA Cashier or the assigned Special Collecting Officer of PEZA in the ecozone,
or print out of the successful confirmation of the Processing Fee payment through the
Electronic Payment and Collection System, and indicating therein the name of the foreign
national and his/her qualified dependents, if applicable
 Checklist of application for PV Extension or for Change of Admission.
 Photocopy of PEZA Certificate of Registration.
 Photocopy of passport of the foreign national (Bio page, Pages containing date of latest arrival
and the valid/expiring/updated visa) with validity of not less than six (6) months from time of
application.
 Notarized Certificate of Employment or Contract of Employment, indicating the period of
employment.
 Notarized Certification signed by the President or Chief Executive Officer or duly authorized
official stating (1) the number of foreign nationals employed vis-à-vis Filipino employees; and
(2) the current percentage of employed foreign nationals over the total work force.
 Certified True Copy of the foreign national’s Alien Employment Permit (AEP), or Certificate of
Exclusion issued by DOLE.
 Comprehensive Bio-data/Resume/Curriculum Vitae duly signed by the applicant.
 Understudy with Undertaking for technical and supervisory positions.
 Organizational chart of the enterprise.
 Birth certificate (children)/marriage certificate (spouse) with English translation and Philippine
embassy/consulate authentication from Applicant’s country of origin OR with Apostille OR
PSA-issued marriage/birth certificate.
 Notarized Affidavit of Support/Guarantee, executed by the PEZA-registered company’s
President/Vice-President.

Done in the City/Province of _________________Philippines, this ___________ Day of


______________, 2022.

_______________
(Signature)
REPUBLIC OF THE PHILIPPINES)
CITY/PROVINCE OF __________) S.S.

SUBSCRIBED AND SWORN to me before me this ___________ day of ____________,


2022, in the City/Province of ____________, affiant exhibited to me his/her ACR or Passport No.
_____________
N00245400 issued at _______________
LOS ANGELES on _____________________.
DECEMBER 16, 2021

____________________
NOTARY PUBLIC
Until December 31, 2022
Doc. No. __________;
Page No.__________;
Book No.__________;
Series of 2022______;

You might also like