EDD.1.F.

006
Revision 2, 01 December 2016

APPLICATION FOR REGISTRATION OF

MEDICAL TOURISM CENTER

_______________________________
BGen CHARITO B. PLAZA (AFPR) MNSA, PhD Date

Director General
Philippine Economic Zone Authority

Madam:

Pursuant to sections 5 and 6 of Republic Act 7916, otherwise known as the Special
Economic Zone Act of 1995, as amended by RA 8748 and PEZA Board Resolution No. 06-
512, I am applying for the declaration of a building with a gross floor area of
_____________________________________________ square meters to be
establish/established on a _________________________________-square meter lot located at
________________________________________________________________ as Medical
Tourism Center to be known as ___________________________________.

The undersigned attest that the documents/information submitted are true and are correct and
that I assume full responsibility for any misrepresentation and/or violation thereof.

Attached hereto are:

1. Endorsement from the Department of Health

2. Duly Accomplished and Notarized Application Form, Anti-Graft Certificate (R.A. 3019) and Applicant's Undertakings
3. SEC Registration Certificate and Articles of Incorporation and By-Laws (including latest GIS)
4. Audited Financial Statements for the last three (3) years of operation, if applicable
5. Board Resolution/Special Power of Attorney/Secretary’s Certificate designating the company’s authorized
representative to PEZA
6. Project Description, which should provide, among others, information on the financial capability of the proponent,
present and proposed land uses, master development plan and schedule for the proposed economic zone
7. Site development plan and vicinity map reflecting various land uses and important verifiable landmarks within one
(1) kilometer radius of the project site
8. Proof of land ownership or any perfected contract/document confirming the applicant’s authority/clearance to use
the land for economic zone development and related purposes
9. Endorsement of the Sangguniang Bayan/Panlungsod for the development of the proposed economic zone (i.e., all
government units of all municipalities and cities with areas included in the proposed economic zone)
10. DAR Conversion Clearance/Exemption Certificate or Housing and Land Use Regulatory Board (HLURB) Zoning
Certification or City/Municipal Zoning Certification, whichever is applicable
11. Copy of the Building Permit, Occupancy Permit and latest Fire Safety Inspection Certificate issued by the LGU for
existing project/s;
12. Verified Survey Returns and Separate Narrative Technical Description of the proposed economic zone area

13. Environmental Compliance Certificate issued by the Department of Environment and Natural Resources

14. Certification from the National Water Resources Board or the Local Water provider that the identified source(s) of
water for the economic zone shall not cause water supply and related problems in adjacent communities

Very truly yours,

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President/General Manager
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Republic of the Philippines

PHILIPPINE ECONOMIC ZONE AUTHORITY
Building 5, DOE-PNOC Complex, Energy Drive, 34 th Street, Bonifacio Global City, Taguig City
Trunk Line No. 551-3451 Loc. 213 & 214 / TeleFax No. 551-3440/E-mail Add: edd@peza.gov.ph

APPLICATION FOR REGISTRATION OF

MEDICAL TOURISM CENTER

Date Filed
O.R. No. / Date

A. NAME OF THE MEDICAL TOURISM CENTER

B. APPLICANT
Company Name
TIN No.
Company Address
Telephone No.
Fax No.
Email Address
Website

C. AUTHORIZED REPRESENTATIVE
Name
Address
Telephone No.
Fax No.
Email Address

D. PROJECT BRIEF
The Proponent

1. Name of Company
2. SEC Registration
Cert. of Registration No.
Date
Amendment (if any)
Nature
Date

3. Nature of Business

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4. Incorporators

NAME NATIONALITY

Use separate sheet/s if necessary

5. Current Stockholders

AMOUNT OF AMOUNT OF
NO. OF
NAME NATIONALITY SUBSCRIBES PAID-UP
SHARES
SHARES SHARES

Use separate sheet/s if necessary

6. Principal Officers

NAME POSITION

Use separate sheet/s if necessary

7. Capital Structure a. Authorized PhP

b. Subscribed PhP
c. Paid-Up PhP

8. Corporate Nationality

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9. Affiliate Company

NAME OF COMPANY CAPITALIZATION

PhP

Use separate sheet/s if necessary

10. Other Project Involvements

YEAR
NAME OF PROJECT DESCRIPTION
ESTABLISHED

Use separate sheet/s if necessary

The Land

1. Location
2. Land Area
3. Existing Land Uses
a. Agricultural (indicate crops planted)

b. Non-Agricultural Barren/Idle Land Grassland

q Others

4. Zoning Classification on or before 15 June 1988

Residential Commercial
Industrial Others

5. Topography Flat Slightly sloping

Hilly Very steep

6. Boundaries North

East

West

South

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(Natural boundaries or land uses abutting the area)

7. Ownership/Right Over Land Full Ownership Lease Contract

MOA Joint Venture Agreement
Others

8. Tenancy Status Tenanted Non-tenanted

9. Proximity to major ports

NAME OF SEAPORT/AIRPORT DISTANCE

10. Off-Site Infrastructure, Facilities & Utilities (brief description)

a. Accessibility and Mode of Transportation:

b. Telecommunication System
i.) Telephone provider
ii.) Other communication services

c. Power System
i.) Power source
ii.) Power franchisee
iii.) Power transmission and distribution

d. Water System
i) Source
ii) Distribution system

The Project
1. Building Gross Floor Area
2. Levels/No. of Storeys
3. Floor Area Allocation

COMPONENT AREA (in sq.m.) PERCENT

Medical Tourism Dedicated Area (Leasable/Saleable)

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Common Utility/Facility Area

Others

TOTAL
Use separate sheet/s if necessary

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2. Status of Development New development Under development

Existing/Fully developed

If new development
i) date of commencement
ii) expected date of completion

If under development
i) percentage completion
ii) date started
iii) expected date of completion

If existing/fully developed
i) date established
ii) occupancy rate
iii) line of business of occupants

3. Labor Requirements

Projected No. of Workers/Employees

Year
During Construction During Operations
1
2
3
Average

4. Proposed/Existing On-Site Utilities, Facilities and Amenities

a. Power System
i) Power source
ii) Power franchisee
iii) Power transmission and distribution
iv) Back-up power generation
◘ Source
◘ Capacity

b. Telecommunication System
i) Telephone provider
ii) No. of lines
iii) Telecommunication backbone
◘ High speed voice and data communication

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◘ Others (i.e. WAN, bandwidth, broadband, satellite services, ISP, etc.)

c. Water Supply System

i) Source
ii) Distribution system

d. Sewerage and Drainage System

e. Sewage Collection, Treatment and Disposal

i) Wastewater collection

ii) Wastewater treatment

iii) Wastewater disposal

iv) Wastewater recycling

f. Solid Waste Disposal System

g. Fire Fighting System

i. Other Utilities, Facilities and Amenities

◘ Air-conditioning System
◘ Elevator System
◘ No. of Parking Slots
◘ Others

6. Proposed Improvements (for existing project, if any)

7. Support Institutions within 1 kilometer radius

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8. Estimated Project Cost Breakdown

COMPONENT AMOUNT
Land Acquisition Cost PhP
Ecozone Development Cost
Land Preparation
Building Construction Cost
Other Costs

TOTAL PhP
Use separate sheet/s if necessary
8.a. Land Development Cost per sq.m.
8.b. Vertical Development Cost per sq.m.

9. Sources of Funds

SOURCE PERCENT SHARE

Use separate sheet/s if necessary

10. Preferred Locator

11. Prospective locator/s with activity, projected investment and employment

Company Name :
Proposed Activity :
Projected Employment :
Projected Investment :
Use separate sheet/s if necessary

12. Marketing Program/Promotional Strategies

13. Environmental Management Program

a. Liquid Waste Management Program

b Solid Waste Management Plan

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c Toxic and Hazardous Waste Management Plan

d Prevention and Abatement of Pollution (air, noise, water)

Done in the City/Province of ____________________________________________________________

this day of 20

___________________________
Affiant
____________________________
Designation

Republic of the Philippines )

) S.
Municipality/City/Province of

Subscribed and sworn to before me this day of 20

in the Municipality/City/Province of

Affiant exhibit to me his Residence Tax Certificate No

issued at on 20

_________________________________
Notary Public
Until December 31, 20______

Doc. No.
Page No.
Book No.
Series of

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APPLICANT'S UNDERTAKINGS

In applying for PEZA registration, the Applicant herewith makes the following representations and commitments:

1 . That the applicant is capable of operating, on a sound and efficient basis, and of contributing to the objectives of
the Philippine Economic Zone Authority in particular and to the development of the national economy in general;

2 . That the project is economically, technically and financially sound;

3 . That the applicant proposes to engage, in good faith, in the creation of a market for its project/product;
4 . That the applicant has installed/undertakes to install an accounting system adequate to identify the investments,
revenues, costs and profits or losses of the project covered by this application separately from the aggregate
investments, revenues, costs and profits or losses of the other business activities of the applicant not registered
under Republic Act No. 7916, as amended by Republic Act 8748 or has established/undertakes to establish a
separate entity for the project/activities covered by this application if so required by the Authority. (Applicable only
if applicant is engaged or proposes to engage in undertaking or activities in addition to the project covered by this
application);

5 . That the applicant shall submit periodic reports and other information, pertaining to its activities in the Ecozone
that the Authority may require;
6 . That the applicant has read Republic Act No. 7916, as amended, and the Rules and Regulations adopted by the
PEZA and commits itself to abide by the provisions thereof as well as amendments thereto;
7 . The applicant will start and operate the project covered by this application within such reasonable time as may be
fixed by the Authority;
8 . That the applicant's Board of Directors has authorized the filing of this application in accordance with the terms
thereof if the applicant is a corporation;
9 . That pursuant to Section 2(p), Rule I of the PEZA Rules, the applicant's income derived within the ecozone shall
be subject to taxes under the National Internal revenue Code pursuant to Section 25 of the Act;
10 . That no Board member or officer of the Philippine Economic Zone Authority has an investment or any other
financial interest, direct or indirect, in the applicant's enterprise; and
11 . That there exists no dummy relationship between any of the stockholders and/or principal officers of the
applicant and any foreign individuals/business entity.

Done in the City/Province of

this day of , 20 .

Affiant

Designation
Republic of the Philippines )
City / Province of ) S.S.

Subscribed and sworn to before me this_________ day of ________________ , 20___ in the City/
Province of ______________________. Affiant exhibited to me his Resident Tax Certificate No. _____________
issued at ___________________________ on _______________, 20___

Notary Public
Until December 31, 20_____
Doc. No.
Page No.
Book No.
Series of 20
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ANTI-GRAFT CERTIFICATE

I, ___________________________________________, of legal age, President/General

Manager/Sole Proprietor of __________________________________________________ with
postal address at _________________________________________________________ after
having been duly sworn, depose and say:

That pursuant to the provisions of Section 3 and 14 of Republic Act 3019 (Anti-Graft Act),
the applicant enterprise, _________________________________________________ has not
given or promised to give, and will not give, any gift to any officer or employee of the PEZA in
connection with the filing and processing of this application, nor it will give such gift to any of said
officers or employees after approval of its application.

That based on the records of the applicant, no Board Member or Officer of the PEZA
has an investment or other financial interest, direct or indirect, in the applicant; and

That this certificate was made with the approval of applicant's Board of Directors or
Management.

Affiant

Subscribed and sworn to before me this__________ day of _____________, 20 _____ in

the City/Province of ________________. Affiant exhibited to me his Residence Tax Certificate No.
_____________________ issued at _______________________ on
_________________________.

Notary Public
Until December 31, 20_____

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