Ods.xls

PASTE 2X2 PHOTO

OPERATOR DATA SHEET

TYPE OF OWNERSHIP

Single Proprietorship

Corporation

Partnership

Cooperative

CASE NUMBER

NO. OF AUTHORIZED UNITS PUJ

TYPE OF SERVICE

TH

SB

TX

TTS

PUB

AC

REG

SHS

AUV

For Individual Operator (Please accomplish below)

LAST NAME FIRST NAME MIDDLE NAME DATE OF BIRTH

SEX

M

F

TIN NO.

For Corporation/Cooperative/Others (Please accomplish below)

NAME OF CORPORATION/COOPERATIVE/OTHERS SEC/CDA REGISTRATION NO. NAME OF AUTHORIZED REPRESENTATIVE POSITION

TIN NO. SEX

DATE OF BIRTH

M

F

General Information

BUSINESS ADDRESS MAILING ADDRESS GARAGE ADDRESS PHONE NUMBER MOBILE NO.

(HOME)

(OFFICE) EMAIL

(FAX) WEBSITE

SPECIMEN SIGNATURE

ATTESTATION AND UNDERTAKING I, __________________________________________, do hereby ATTEST that the foregoing information are complete and true to the best of my knowledge and belief. I further UNDERTAKE to inform the Board of any changes/amendments to the above details within fifteen (15) days from occurrence of said changes/ amendments. ______________________________________ Signature over Printed Name

I, __________________________________________, do hereby ATTEST that the foregoing information are complete and true to the best of my knowledge and belief. I further UNDERTAKE to inform the Board of any changes/amendments to the above details within fifteen (15) days from occurrence of said changes/ amendments. ______________________________________ Signature over Printed Name