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CPC Application Form

NWRB application form for certificate of public convenience for water supply

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CERTIFICATE OF PUBLIC CONVENIENCE
NATIONAL WATER RESOURCES BOARD FOR WATER SUPPLY APPLICATION
8th Floor, NIA Building, EDSA, Quezon City
Telefax : 920-27-14
CASE NO.
PLEASE ACCOMPLISH THIS FORM IN SIX (6) COPIES
NAME OF APPLICANT

MAILING ADDRESS

WATER PERMIT NO.
SOURCE

CONTACT NO.

LOCATION
CITIZENSHIP

TIN

SERVICE AREA
Subdivision:

DATE OF OPERATION
Existing CPC/N No., if for renewal

Barangay:
Municipality:

Provisional Authority Required

Province:

Yes

TYPE OF UTILITY
[ ] Subdivision / HOA
[ ] Rural Water & Sanitation Association
[ ] Cooperative
[ ] Bulk Water Seller/Peddler
[ ] Others ________________________
(specify)

KIND OF WATER SYSTEM
[ ] Draw & Fill

FILING FEE
a. Amount ____________
b. O. R. No. ___________
c. Date ________________

No

NO. OF CONNECTIONS
a. with water meters _____________________
b. w/o water meters ______________________
c. meter tested ____________________
c.1 tested by ____________________
c.2 date tested ____________________
d. for bulk seller /peddler
Average volume of water delivered in cubic meters per day
________________________
[ ] Float

[ ] Direct Pumping

LIST OF DOCUMENTARY REQUIREMENTS

( )
( )

( )
( )
( )

( )
( )
( )

Articles of Incorporation/Partnership/ DTI Registration
Board resolution (for corporations and partnerships) or
special power of attorney (for single proprietorships)
authorizing the signatory to sign and file the application
Copy of Approved Water Permit/s
Copy of Official Receipt/s of Annual Water Charges
Copy of Latest Certificate of Potability issued by
City/Municipal Health Officer where source is located
with Results of Bacteriological, Physical & Chemical
Impurities conducted by laboratory of DOH
Plan of Water Distribution System
Plan, Elevation of Cross-sectional Views of
Tank/Reservoir
Plan, Elevation of Cross-sectional Views of Pump House,
Machinery & Equipment

NOTE: USE 5- YEAR TARIFF MODEL TO COMPLY ON
FINANCIAL REQUIREMENTS
( ) Latest Audited Financial Statement ¹
( ) Actual Balance Sheet for Water Operations ¹²‫׳‬
( ) Actual Income Statement for Water Operations ¹²‫׳‬
( ) List of Existing Assets in Service Subject to Return ¹
Itemized Projected Financial Statements for Water
Operations for 5 years
( ) Income Statements
( ) Funds Flow
( ) Balance Sheet
( ) Assumptions
( ) Business Plan & Itemized List of Required Investments
for the Next 5 yrs.
( ) Proposed Tariff Schedule
( ) Levels of service agreed with consumers commensurate
with proposed rates
( ) Others
For new CPC applicants, last 2 years
For old applicants, last 2 years
2 If applicant has another operations other than water supply
1

I HEREBY CERTIFY THAT THE INFORMATION
GIVEN
ABOVE
AND
THE
DOCUMENTS
SUBMITTED ARE TRUE AND CORRECT TO THE
BEST OF KNOWLEDGE AND BELIEF

Signature of Water Utility Representative

SUBSCRIBED AND SWORN TO BEFORE ME ON THIS DATE

Notary Public / Administering Officer
 
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