Republic of the Philippines

City of Puerto Princesa

Barangay San Miguel
OFFICE OF THE SANGGUNIANG BARANGAY
(BAC-GOODS)
BIDS AND AWARDS COMMITTEE FOR THE PROCUREMENT OF GOODS

APPLICATION FOR ELIGIBILITY TO BID

(Procurement of Goods)

I, ________________________________of legal age, Filipino, with postal

and business address located at __________________________________, in
my capacity as _____________________________of the herein below-
mentioned business entity, hereby applies for ELIGIBILITY to
participate in the forthcoming public bidding relative to the
procurement of goods by the Barangay Government of San Miguel,
Puerto Princesa City for Fiscal Year- 20_____.

In support hereto, I hereby submit the below- listed

documentary requirements.

DONE, this _______day of _________________, 20____, Puerto

Princesa City

___________________________________
{Business Name}
By:

___________________________________
{Signature Over-Printed Name}

___________________________________
{Official Designation}
DOCUMENTARY REQUIREMENTS

{ } Department of Trade and Industry (DTI) business name

registration or Securities and Exchange Commission (SEC)
Registration Certificate or Cooperative Development Authority
(CDA) Certificate of Registration, in case of cooperative.

Business
Name:_______________________________________________________
Address:_____________________________________________________________
Product
Line:_________________________________________________________

{ } BIR Registration Certification, which contains the Taxpayer’s

Identification Number

Taxpayer’s Identification
Number:________________________________________

{ } Audited financial statement, stamped, received by the BIR or

its duly accredited and authorized institutions, for the immediately
preceding calendar year (CY-20_____) showing among others the
total assets and liabilities

# PARTICULARS CALENDAR Year

2011
1 Total Assets _______________________
2 Current Assets _______________________
3 Total Liabilities _______________________
4 Currents Liabilities _______________________
5 Net Worth (1-3) _______________________
6 Net Working Capital (2-4) _______________________

{ } Valid and current ( CY-2011 ) Mayor’s Permit-Puerto Princesa

City

{ } Letter of Authority of Signatory (Special Power of Attorney)

Name of Authorized
Signatory:__________________________________________

{ } Statement/sworn affidavit of the prospective bidder that is not

“blacklisted” or barree from bidding by the Government or any of
its agencies, offices, corporations of LGU’s, including non-inclusion
in the Consolidated Blacklisting Report issued by the Government
Procurement Policy Board (GPPB)

{ } Statement/sworn affidavit of the prospective bidder that is not

related top the Local Chief Executive, or to any member of the BAC-
GOODS or to any members of its Secretariat and or any member of
its Technical Working group, by consanguinity or affinity up to the
third civil degree

{ } Letter of the prospective bidder authorizing the BAC-GOODS or

its duly representative/s to verify any or all documents submitted
for the eligibility check/certification under-oath from the
prospective bidder that each of the documents submitted in
satisfaction of the eligibility requirements is an authentic and
original copy or a true and faithful reproduction or copy of the
original, complete, and that all statements and information provided
therein are true and correct

{ } Valid Joint Venture Agreement (JVA), in case of a joint venture

ELIGIBILITY RATING

( ) ELIGIBLE ( ) INELIGIBLE

Product Line:
___________________________________________________________________

Net Financial Contracting Capacity (NFCC): P

________________________________

NOTED:

PRINCE RUSSELL T. GLORIANI

Chairman, BAC-GOODS

SPECIAL INSTRUCTIONS

1. All pertinent and applicable data under Documentary

Requirements portion of this form must be properly filled-up and
duly accomplished by the applicant.
2. This application form, including all applicable documentary
requirements to be submitted to the BAC-GOODS Secretariat must
be in Three (3) sets, and each set must be contained and properly
bind in a long folder.