Republic of the Philippines
Department of Transportation
LAND TRANSPORTATION FRANCHISING & REGULATORY BOARD
East Avenue, Quezon City
OPERATOR DATA SHEET
2x2 Photo
TYPE OF OWNERSHIP Single Proprietorship Corporation
Partnership Cooperative
1. CASE NUMBER ________________ NO. OF AUTHORIZED UNITS _________________
TYPE OF SERVICE PUJ SB AUV
` TH TX PUB_AC_REG
TTS SHS
OTHER EXISTING FRANSHISES _____________________________________________
CASE NUMBER TYPE OF SERVICE NO. OF AUTHORIZED UNITS GARAGE LOCATION
GARAGE ADDRESS WITH GARAGE DIMENSION
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Direct Line 434-80-25 up to 36 Fax no. 921-2616
426-25-05, 426-25-01 426-2485
_____________________________________________________________________________________
_____________________________________________________________________________________
NO. OF UNITS PER GARAGE_______________________________________________________________
OWNED YES NO
LEASED YES NO
NAME OF LESSOR_______________________________________________________________________
II. FOR INDIVIDUAL OPERATOR:
LAST NAME ___________________________________________________________________________
FIRST NAME___________________________________________________________________________
MIDDLE NAME_________________________________________________________________________
DATE OF BIRTH________________SEX: F M
TIN NO.____________________
BUSINESS ADDRESS ____________________________________________________________________
MAILING ADDRESS ______________________________________________________________________
PHONE NUMBER _______________________________________________________________________
EMAIL________________________________________________________________________________
SPECIMEN SIGNATURE
III. FOR CORPORATION/COOPERATIVE/OTHERS
NAME OF CORPORATION/COOPERATIVES/OTHER ____________________________________________
_______________________________________________________________________________________
SEC/CDA REGISTRATION NO. ______________________TIN NO. _________________________________
BUSINESS ADDRESS _____________________________________________________________________
MAILING ADDRESS _____________________________________________________________________
PHONE NUMBER _____________________________________________________________________
EMAIL ________________________________________________________________________________
IV. Authorized Representative [Note: Only the authorized representative identified in this sheet will be
allowed to transact business in the agency for and on behalf of the owner]
LAST NAME____________________________________________________________________________
FIRST NAME ___________________________________________________________________________
MIDDLE NAME _________________________________________________________________________
DATE OF BIRTH________________SEX: F M
TIN NO.____________________
BUSINESS ADDRESS ____________________________________________________________________
MAILING ADDRESS ______________________________________________________________________
PHONE NUMBER_______________________________________________________________________
EMAIL_______________________________________________________________________________
SPECIMEN SIGNATURE
V. Authorized Drivers
Name Address Driver’s Li e se Nu er Expiration Date
Operator undertakes that all information stated in this sheet are true and correct. Any misrepresentation
and/or unlawful withholding of information will warrant outright denial and/or cancellation of the franchise
in accordance with the Public Service Act. The Board reserves the right to VERIFY all information in this
datasheet and to institute appropriate criminal prosecution for any act prejudicial to the public interest.
ATTESTATION AND UNDERTAKING
I, ______________________________________, do hereby ATTEST that the foregoing
information are complete, true and correct to the best of my knowledge and belief. I commit to inform the
Board in writing any subsequent changes in this data sheet within 15 days from knowledge thereof.
______________________________
Signature over Printed Name
SUBSCRIBED AND SWORN TO before me this _____________________________, a notary
Public for and in the city of ____________________________________________, the affiant showing to
me his/her identification card with no. _________________________.
NOTARY PUBLIC
