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Contractor's Confidential Application Statement for Registration
DPWH application form for contractor's confidential statement
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Department of Public Works and Highways
CENTRAL OFFICE
Registry of Contractors for Civil Works Projects
Contractor’s Confidential Application Statement
for Registration (CCASR)
(Please read the attached Instructions)
I, __________________________________ of legal age, with postal address at
___________________________________________, after having been duly sworn in
accordance with the law, hereby depose and say:
1.
That I am the _________________________________________________________ of
the __________________________________________ duly authorized to make this
statement, as evidenced by the attached written authority from the proprietor/governing
board of the firm,
2.
That I hereby present the following information for registration with the Department of
Public Works and Highways.
A. GENERAL INFORMATION
1. Name of Firm/Company : ___________________________________________________________
a. Head Office Address
: Number: _________ Street Name: ______________________________
Municipality/City: ______________ Province: ____________ Region: ___
Postal Code: ________________ Country: _________________
b. Telephone Number
: _________________________
c. Fax Number
: _________________________
d. Email Address
: _________________________
e. Company TIN
: _________________________
2. Foreign Contractors Only
a. Nationality
: ______________________________
b. Philippine Address
: Number: _________ Street Name: ______________________________
Municipality/City: ______________Province: ____________ Region: ___
Postal Code: ________________
c. Telephone Number
: _________________________
d. Fax Number
: _________________________
e. Email Address
: _________________________
f. Percentage of Filipino : __________________ (if applicable)
Ownership
3. Person Managing the Affairs of the Firm: Attach Annex “A”
a. Name
: _______________________________
b. Designation
: _______________________________
c. Tax ID No.
: _________________________
d. Birthdate
: _________________________
e. Picture
2x2 ID Picture
f. Signature :
Signature
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4. Authorized Liaison Officers: Attach Annex “B”
a.
b.
c.
d.
Name
Designation
Tax ID No.
Birthdate
:
:
:
:
1.
1.
1.
1.
_________________ 2.
_________________ 2.
_________________ 2.
_________________ 2.
_________________ 3.
_________________ 3.
_________________ 3.
_________________ 3.
_________________
_________________
_________________
_________________
f.
2x2 ID Picture
2x2 ID Picture
2x2 ID Picture
Signature
e. Picture:
Signature
Signature
Signature:
A. LEGAL ASPECTS
1. Ownership
NAME(S) of
Owner/Stockholders
(for Corporation)
Tax ID Number
(TIN)
Birthdate
Signature
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2. City/Municipal Business Permit: Attach Annex “C”
Date issued: _________________________
Validity period: ______________________
Tax Identification Number: _____________
3. BIR Tax Clearance (per EO 398, series of 2005): Attach Annex “H”
Date issued: _________________________
Validity period: ______________________
Tax Identification Number: _____________
4. PhilGEPS Registration
Date issued: _________________________
Validity period: ______________________
Certificate Number: _____________
B. TECHNICAL ASPECTS (Contractor’s Work Experience)
1. PCAB License Information
Contractor Particulars
(Please refer to your PCAB License)
Sole Proprietor: Attach Annex “D”
Head Office Location (Region):
Partnership: Attach Annex “E”
Corporation: Attach Annexes “E” and “F”
License Particulars
License First Issue Date (mm/dd/yy) ___/___/___
License No.
Validity Period of this License/Renewal (mm/dd/yy)
From: ___/___/___ To: ___/___/___
Principal Classification:
Category
Other Classifications
Registration Particulars
Registration Date (mm/dd/yy):
___/___/___
Validity Period of this Registration (mm/dd/yy):
Kinds of Project
Number:
From: ___/___/___ To: ___/___/___
Respective Size Ranges
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2. List of all contracts completed by the contractor both in government and in the private sector: Attach Annex “I”
Contract
ID
Contract Name
Owner
Contractor’s
Role &
Participation
%
Contract Date
Start
mm/dd/yy
Actual
Completion
mm/dd/yy
Categories of
Work Code
Refer to
Attachment A
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Dimensions
Refer to
Attachment
A
Total As Built
Cost
Per Work
Category (PhP)
3. List of all on-going contracts including those already awarded but not yet started, both in government and in the private sector: Attach Annex “J”
NOTE: Cost must be in Philippine Pesos computed on the date of the signing of the contract.
Contract Date
Contract
ID
Name of
Contract
Owner
Participation
%
Start
mm/dd/yy
Complete
mm/dd/yy
Percent
WA
TE
Key: WA = Work Accomplished TE = Time Elapsed
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Categories
of Work
Code
Refer to
Attachment A
Dimen
-sions
Estimated
Total Cost per
Work
Category
C. FINANCIAL ASPECTS (Amounts shall be in Philippine Pesos): Attach Annex “K”
Amount
Total Assets
Current Assets
Total Liabilities
Current Liabilities
Total Net Worth
Current Net Worth
Gross Annual Turnover
(construction)
Taxpayer Identification Number (TIN) ____________________________
D. AFFIDAVIT
I hereby certify that all information provided herein, including the annexes and
enclosures thereto, is true and correct, and I hold myself liable, criminally or civilly, for any
misrepresentation or false statement made herein.
I hereby authorize the Department of Public Works and Highways to investigate and
verify the said information.
In witness thereof, I have hereunto affixed my signature this ______ day of
________________, 20____ at _____________________________________, Philippines.
___________________________
(Affiant)
(Republic of the Philippines
)
PROVINCE/CITY OF __________________)
SUBSCRIBED and SWORN TO before me this _______ day of ____________________,
20_____ at _____________________ affiant exhibited to me his/her Community Tax Certificate
No. ___________ issued at ________________________ on ____________________.
Doc. No.
Page No.
Book No.
Series No.
_____________
_______________
_______________
_______________
________________________
Notary Public
Until 31 December 20 _______
PTR No. : _______________
Issued at : _______________
Issued on : _______________
TIN
: _______________
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CONTRACTOR’S CONFIDENTIAL APPLICATION STATEMENT FOR REGISTRATION (CCASR)
INSTRUCTIONS FOR CONTRACTOR’S APPLICATION
1.
The Contractor-Applicant shall accomplish/answer all items in the Application Statement using
the English language. Answers must be given to all questions in the aforesaid statement. All
blanks shall be properly filled up. If necessary, additional sheets may be added to the form or,
if the form has limited space, it can be reproduced and enlarged to suit the ContractorApplicant’s needs. Documents submitted on forms or in any format other than that prescribed
in the aforesaid Statement shall be considered non-complying and will be rejected outright.
Forms that may require attachments shall be clearly marked, i.e., Attachments to Form No.1;
Attachments to Form No. 2, etc.
2.
The information/data submitted by the Contractor-Applicant are to be used by the DPWH in
determining, according to its judgment, the eligibility and qualification of the Contractor. In
view thereof, Contractor-Applicants are encouraged to communicate with the DPWH for any
clarification or interpretation of the documents. Requests for reconsideration will not be
entertained on any erroneous interpretations or conclusions made by the Contractor-Applicant.
A Contractor-Applicant submitting its qualifications as a prospective Contractor for review and
consideration waives any claim against any decision thereon. The signing by the Contractor or
his duly authorized representative of the Contractor-Applicant’s Application Statement for
Registration acknowledges the truth and correctness of all statements made therein;
otherwise, the Contractor shall be liable for perjury as provided in the Revised Penal Code.
3.
Aside from the main Contractor’s Confidential Application Statement for Registration, the
following documents shall be annexed to and form part of the Statement:
Annex “A”
Appointment or authority of the Authorized Manager of the Organization with
specimen signature duly notarized.
Annex “B”
Appointment or authority of the officially designated Liaison Officer with specimen
signature duly notarized and copies of two (2) valid Government ID’s showing
his/her proper identification.
Annex “C”
Certified True Copy of Contractor’s PCAB License for the current year
Annex “D”
Certified True Copy of DTI (sole proprietorship), CDA (cooperatives) or SEC
(corporation)
Annex “E”
Certified True Copy of Certificate of PhilGEPS Registration (Platinum Membership)
Annex “F”
Certified True Copy of Articles of Incorporation (if applicable)
Annex “G”
Certified True Copy of valid and current Mayor’s Business Permit
Annex “H”
Certified True Copy of BIR Tax Clearance, per E.O. 398, series 2005
Annex “I”
Certified True Copy of Contract Agreement and of Certificate of
Completion/Acceptance from the Implementing Office/Owner, with scope of work,
and Contract cost for completed contracts
Annex “J”
Certified true copy of Contract Agreement from the Implementing Office/Owner,
with scope of work, Contract costs and statement from the Implementing Office
as to %WA and %TE for all ongoing contracts, and those already awarded but
not yet started, including certified true copy of NTP.
Annex “K”
Audited Financial Statement as reflected in Contractor’s Income Tax Return
stamped received by the Bureau of Internal Revenue
Annex “L”
Letter authorizing verification of the integrity of the Registration documents
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4.
The Contractor’s Confidential Application Statement for Registration, including Annexes, shall
be submitted in one (1) envelope. The envelope should be captioned “Application for
Registration” and submitted preferably to the DPWH Central Office: Procurement Service. All
documents submitted shall be treated as confidential and will not be returned.
5.
The DPWH will inform all applicants of the result of their application. It reserves the right to
accept or reject any application without any liability to the affected applicants or any
obligation to inform the applicants of the grounds for the action taken thereon.
Attachment A - TABLE OF MAJOR CATEGORIES OF WORK
Major
Work
Category
Code
Work Category Description
Work Category
Measure Code
BCB
Bridges: Construction - Bailey
lm.
BCSDP
Bridges: Construction - Steel (Superstructure) - with Driven Piles
lm.
BCSCP
Bridges: Construction - Steel (Superstructure) - with Cast-in-Place Piles
lm.
BCCDP
Bridges: Construction - Concrete (Superstructure) - with Driven Piles
lm.
BCCCP
lm.
BRHSDP
Bridges: Construction - Concrete (Superstructure) - with Cast-in-Place
Piles
Bridges: Rehabilitation - Steel (Superstructure) - with Driven Piles
BRHSCP
Bridges: Rehabilitation - Steel (Superstructure) - with Cast-in-Place Piles
lm.
BRHCDP
Bridges: Rehabilitation - Concrete (Superstructure) - with Driven Piles
lm.
BRHCCP
lm.
BRTSDP
Bridges: Rehabilitation - Concrete (Superstructure) - with Cast-in-Place
Piles
Bridges: Retrofitting - Steel (Superstructure) - with Driven Piles
BRTSCP
Bridges: Retrofitting - Steel (Superstructure) - with Cast-in-Place Piles
lm.
BRTCDP
Bridges: Retrofitting - Concrete (Superstructure) - with Driven Piles
lm.
BRTCCP
Bridges: Retrofitting - Concrete (Superstructure) - with Cast-in-Place Piles
lm.
BCCWOP
Bridges: Construction - Concrete (Superstructure) - without Piles
lm.
BCSWOP
Bridges: Construction - Steel (Superstructure) - without Piles
lm.
BRHCWOP
Bridges: Rehabilitation - Concrete (Superstructure) - without Piles
lm.
BRHSWOP
Bridges: Rehabilitation - Steel (Superstructure) - without Piles
lm.
BRTCWOP
Bridges: Retrofitting - Concrete (Superstructure) - without Piles
lm.
BRTSWOP
Bridges: Retrofitting - Steel (Superstructure) - without Piles
lm.
RCA
RCG
RCP
Roads: Construction - Asphalt
Roads: Construction - Gravel
Roads: Construction - PCCP
km.
km.
km.
lm.
lm.
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RRA
RRP
RCTP
RCSPNS
Roads: Rehabilitation - Asphalt
Roads: Rehabilitation - PCCP
Roads: Construction - Tunnel - PCCP
Roads: Construction - Slope Protection using non - structural measures
(e.g. vetiver, coconet, other vegetation)
km.
km.
RCSPS
Roads: Construction - Slope Protection using Structural Measures (e.g.
Revetment, Retaining structures, Wirenet)
km.
RM
BM
TEMS
Roads: Maintenance
Bridges: Maintenance
Traffic Engineering and Management System (including Road Safety
Devices)
Buildings: Construction - with Piles - Low Rise - Concrete (Frame) - Driven
Piles (1 to 5 Storeys)
km.
km.
lm.
BICWPLCDP
km.
storeys
BICWPLCCP
Buildings: Construction - with Piles - Low Rise - Concrete (Frame) - Castin-Place Piles (1 to 5 Storeys)
storeys
BICWOPLC
Buildings: Construction - without Piles - Low Rise - Concrete (Frame) (1 to
5 Storeys)
Buildings: Construction - with Piles - High Rise - Concrete (Frame) Driven Piles (6 & above Storeys)
storeys
BICWPHCCP
Buildings: Construction - with Piles - High Rise - Concrete (Frame) - Castin-Place Piles (6 & above Storeys)
storeys
BICWOPHC
Buildings: Construction - without Piles - High Rise - Concrete (Frame) (6 &
above Storeys)
Buildings: Construction - with Piles - Low Rise - Steel (Frame) - Driven
Piles (1 to 5 Storeys)
Buildings: Construction - with Piles - Low Rise - Steel (Frame) - Cast-inPlace Piles (1 to 6 Storeys)
storeys
Buildings: Construction - without Piles - Low Rise - Steel (Frame) (1 to 5
Storeys)
Buildings: Construction - with Piles - High Rise - Steel (Frame) - Driven
Piles (6 and above Storeys)
storeys
BICWPHSCP
Buildings: Construction - with Piles - High Rise - Steel (Frame) - Cast-inPlace Piles (6 and above Storeys)
storeys
BICWOPHS
storeys
BIR
BIRTL
Buildings: Construction - without Piles - High Rise - Steel (Frame) (6 and
above Storeys)
Buildings: Repair
Buildings: Retrofitting - Low Rise
BIRTH
Buildings: Retrofitting - High Rise
storeys
FCG
FCDG
FCRB
FCSP
Flood
Flood
Flood
Flood
FCSPNS
Flood Control: Construction - Slope Protection using non - structural
measures (e.g. vetiver, coconet, other vegetation)
BICWPHCDP
BICWPLSDP
BICWPLSCP
BICWOPLS
BICWPHSDP
Control:
Control:
Control:
Control:
Construction
Construction
Construction
Construction
-
Gates
Dam with Gates
Retarding Basin
Shore Protection (Seawall, Breakwater)
storeys
storeys
storeys
storeys
storeys
storeys
unit
unit
cu.m.
lm.
lm.
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FCSPS
Flood Control: Construction - Slope Protection using Structural Measures
(e.g. Revetment, Retaining structures, Wirenet)
lm.
FCD
FMDRE
cu.m.
cu.m.
FCCE
Flood Control: Construction - Dams
Flood Control: Maintenance - Dredging, Desilting, River
Rechanneling/Excavation Works
Flood Control: Construction - Channel Excavation
HD
Harbors: Dredging
cu.m.
FCN
Flood Control: Construction - Drainage (Closed and open) Conduits
lm.
FCP
FCDKL
FCBPS
Flood Control: Construction - Pumping Station
Flood Control: Construction - Dikes/Levees
Flood Control: Construction - Bank Protection Structure
unit
lm.
WSL1
Water Supply (Level 1): Construction (Shallow Wells/Rainwater Collectors)
lm.
WSL2&3
Water Supply (Level 2 & 3): Construction (Piped Water with
Communal/Private Water Point)
PCCWDP
Ports/Harbors: Construction - Causeway/Wharf - with Driven Piles
lm.
PCCWCP
Ports/Harbors: Construction - Causeway/Wharf - with Cast-in-Place Piles
lm.
PMCWDP
Ports/Harbors: Maintenance - Causeway/Wharf - with Driven Piles
lm.
PMCWCP
Ports/Harbors: Maintenance - Causeway/Wharf - with Cast-in-Place Piles
lm.
cu.m.
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ANNEX “L”
ANNEX “L”
LETTER AUTHORIZING VERIFICATION OF THE INTEGRITY OF REGISTRATION
DOCUMENTS
Name of the Head of the Procuring Entity
Position of the Head of the Procuring Entity
Name of the Procuring Entity
Address
Dear __________________:
________________________________________________________________________
(Name of Firm)
I hereby request that our application for inclusion of the above-mentioned firm in the DPWH
Registry of Contractors for Civil Works be approved.
I am fully aware that:
1.
all documents submitted in support of this application are subject to verification by the
DPWH, and
2.
any discovered misrepresentation of information and/or manifestations of fraud on the
application documents submitted by our firm applicant or its Authorized
Representative/Agent/Liaison Officer shall be subjected to investigation which may result in
the disapproval/denial/suspension/revocation of this application and blacklisting of our firm
and myself as its Authorized Managing Officer; and
Name and Signature
Authorized Managing Officer
Republic of the Philippines)
_____________________) S.S.
SUBSCRIBED AND SWORN TO before me this ________ day of ___________________, 20____
at ______________________; affiant exhibited to me his Community Tax Certificate No.
_______________ issued at __________________ on _________________ 20 ___.
Doc. No. ___________;
Page No. ___________;
Book No. ___________;
Name and Signature
NOTARY PUBLIC
(Until December 31, 20__)
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