NTC Form No.:

Reference No:

APPL-11

Republic of the PhilippinesNATIONAL TELECOMMUNICATIONS COMMISSIONBIR Road, East-Triangle, Diliman, Quezon City

APPLICATION FOR VAS REGISTRATION

INSTRUCTIONS: All blanks must be filled up properly. lndicate "N/A" for items not applicable. Dulyaccomplished form must be submitted with reguird/supporting documents. Pint allentries in block or CAPITAI IEITERS

TYPE: i::::i New i::::i Ren i i Modification

1 APPLICANT

2 BUSINESS ADDRESS3 CONTACT NO(s)4 NTC PERMIT NO.5 FRANGHISE (R.A. No.l

EMAIL ADD:VALIDITY : (lf Applicable)

(lf Applicable)

6 TYPE OF FIRM: (Check appropriate box)

i ! Corporation i-__jL---Ji'---i i----jL___j Single Proprietorship t___-j

7 HAS APPLICANT BEEN KNOWN BY ANOTHER NAME?i----1"YesiiNoL---l L___d

lf Yes, Indicate the name(s) and address(es) of former name:

Partnership

Others, please specify

8 LIST OF VAS OFFERED :AB

cD

E

F

G

9 CERTIFICATIONI HEREBY CERTTFY that all above entries are true and conect and that I shall be held liable for any willful falsestatements made in this application under the Revised Penal Code. Any false statement or misrepresentationmade in connection with this application shall constitute a valid ground for the denial of this application and/orcancellationl revocation of the pemit to be granted.

Signature over Printed Name of Applicant Ior Authorized Representative

Date

iORHKAMOUNT:

I,II

,20-.

PLEASE SEE BACK HEREOF FOR THE REQUIREMENTS TO BE SUBMITTED

IHIS FARM /S /VOT FOR SAIF AND CAA/ BE REPRODUCED

IIIIa

IItIIII CASHIER

lRevision l.lo.: :lRevision Date: !

NTC REGIONAL OFFICE NO.:

DOC UM ENTARY REQU I REM ENTS FOR SUBT''SS'OAI

NEW1 Duly accomplished Application form forVAS Application2 List and description of each of the value added services intended to be offercd3 List of equipment and materials to be used forthe system, including equipment to be installed, if any.4 Functional block diagram, system configuration and a brief description of the proposed system.

^ Copy of any Interconnection Agreements needed to put the system into operation (Copies of Lease Agreement- wtth the Public Canier).

o Certified True Copy of Securities and Exchange Commission Registr:ation and Articles of Incorporations/DTlo Permit.

7 Latest Audited Financial Statement.8 Schedule of Service Rates.

RENEWAL1 Duly accomplished Application form forVAS Application2 Original copy of Certificate of VAS Registration3 l-atest schedule of Serviice Rates.

MODIFICATION1 Duly accomplished Application form for VAS Application2 Original copy of Certificate of VAS Registration3 Description of each of the value added services intended to be offered4 List of equipment and materials to be used forthe system, including equipment to be installed, if any.5 Functional block diagram, system configuration and a brief description of the porposed system.

Office Address:Contact No.:Fax No.:E-mailAddress: