Republic of the Philippines
Department of Finance
BUREAU OF CUSTOMS 2x2 ID Picture
1099 Manila
INTELLIGENCE GROUP (IG)
ACCOUNT MANAGEMENT OFFICE (AMO)
Date: _________________
APPLICATION FOR ACCREDITATION AND REGISTRATION
AS CUSTOMS BROKER
1. Applicant Name: ______________________________TIN No.: _________________
Date of Birth: ________________________ Place of Birth: _____________________
Sex: _________ Civil Status: ______________ Age: _____ Nickname: ____________
Customs Broker Certificate No.: ________ PRC No.: ________ Valid up to: ________
2. Residence Address:
_____________________________________________________________________
_____________________________________________________________________
Contact No.: _____________________
3. Office Business Address:
_____________________________________________________________________
_____________________________________________________________________
Fax No.: _______________________ Email Address: _________________________
Contact Person: _____________________ Tel No.: ___________________________
Business Name (if any): _________________________________________________
4. Financial Status as of: _______________Net Worth Php _______________________
Total Resources Php ____________________________________________________
5. Profile of Practice as Customs Broker for the past five (5) years:
Inclusive Dates Name of Company Port(s) Concerned
6. Academic Background:
Dates of
Education Name of Institution Degree Received
Attendance
7. Basis for issuance of Customs Broker Certification:
( ) Passed Exam ( ) Pursuant to RA 1937
8. Attachments to support application paper
( ) BCOR evidencing payment of application fee
( ) Valid PRC ID
( ) List of Clients with complete address and contact details
( ) List of authorized representatives with personal details, photos and specimen signature
( ) Printed CPRS Application Profile and updated email notification of “STORED” CPRS profile
9. Do you have any pending
(a) Criminal case? ( ) YES ( ) NO (b) Administrative case? ( ) YES ( ) NO
If “YES”, state details of the offense _________________________________________
________________________________________________________________________
________________________________________________________________________
10. Have you ever been convicted of any crime or violation of law or regulation by any court
or tribunal? ( ) YES ( ) NO
If “YES”, state details of the offense/ violation, name and branch of the court/ tribunal,
date of promulgation of decisions, etc. ______________________________________
________________________________________________________________________
________________________________________________________________________
11. Have you ever been administratively sanctioned or meted any penalty by the Bureau of
Customs or Professional Regulation Commission for any violation of law or regulation
resulting in the suspension or revocation of you Customs Brokers License/ Certificate of
Accreditation issued by a Collector of Customs/ the Commissioner of Customs or your
Customs Broker Certificate/ Professional Identification card issued by the Professional
Regulation Commission? ( ) YES ( ) NO
If “YES”, state complete details _______________________________________________
________________________________________________________________________
________________________________________________________________________
12. Have you ever been barred from transacting customs business and/or entering the customs
premises or zones? ( ) YES ( ) NO. If “YES”, give details.
________________________________________________________________________
________________________________________________________________________
If the barring order was not perpetual, has the order been already lifted ( ) YES ( ) NO.
If “YES”, give details of the order and date of lifting.
________________________________________________________________________
________________________________________________________________________
13. Have you retired, forced to resign or dropped from employment in the public or private
sector? ( ) YES ( ) NO. If “YES”, state the circumstances/details.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
14. Are you related by consanguinity or affinity to any present official or employee of Bureau
of Customs? ( ) YES ( ) NO.
If “YES”, state their name(s), degree of relationship, and present position and assignment.
________________________________________________________________________
________________________________________________________________________
Character Reference: (Not related to you by consanguinity or affinity)
Name Degree Residence/ Address Tel No.
REPUBLIC OF THE PHILIPPINES )
___________________________ ) S.S
SWORN UNDERTAKING
I hereby certify under oath that all the above information are true and correct; all
documents submitted in support of its application are true copies of the original, subject
to verification; any misrepresentation and/or manifestation of fraud in this application shall
be a ground for disapproval of my application, and blacklisting of our firm and the
undersigned as the applicant.
As specified in Section 2.2 of CMO No. 4-2014, I hereby undertake to (a) to receive
notice by e-mail; (b) to strictly abide with existing rules and regulations on the Statement
of Full Description of Imported Articles covered by entry declarations; (c) to notify the BOC-
AMO of any changes in the information contained in the application for accreditation; and
(d) to obtain knowledge of the contents of a declaration, and to attest to the veracity
thereof.
I fully understand that failure to comply with the undertaking will result in the
cancellation and revocation of the accreditation as customs broker, without prejudice to
the imposition of any other criminal sanction for violation of the Tariff and Customs Code
of the Philippines, and other customs laws and regulations.
____________________ __________________________ Right Thumbmark
Date Accomplished Name and Signature of Applicant
SPECIMEN SIGNATURE:
____________________ ____________________
____________________ ____________________
SUBSCRIBED AND SWORN to before me this ______ day of _____________
In Manila, Philippines, affiant exhibiting to me his/her ________________________
Issued at ______________________________ on ___________________________
Doc No. ____
Page No. ____
Book No. ____
Series of ____
