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CPC Application Form

This document is an application form for a Certificate of Public Convenience (CPC) from the National Water Resources Board of the Philippines for a water supply operation. The form requests information about the applicant, the water source and system, service area, type of utility, number of connections, required documents, and certification. It notes that a 5-year tariff model must be used to comply with financial requirements. The applicant must sign and swear to the accuracy of the information before a notary public.

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Agnes Bianca Mendoza
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1K views1 page

CPC Application Form

This document is an application form for a Certificate of Public Convenience (CPC) from the National Water Resources Board of the Philippines for a water supply operation. The form requests information about the applicant, the water source and system, service area, type of utility, number of connections, required documents, and certification. It notes that a 5-year tariff model must be used to comply with financial requirements. The applicant must sign and swear to the accuracy of the information before a notary public.

Uploaded by

Agnes Bianca Mendoza
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Republic of the Philippines

NATIONAL WATER RESOURCES BOARD CERTIFICATE OF PUBLIC CONVENIENCE


8th Floor, NIA Building, EDSA, Quezon City FOR WATER SUPPLY APPLICATION
Telefax : 920-27-14
CASE NO.
PLEASE ACCOMPLISH THIS FORM IN SIX (6) COPIES
NAME OF APPLICANT MAILING ADDRESS WATER PERMIT NO.
SOURCE
CONTACT NO.
LOCATION
CITIZENSHIP TIN DATE OF OPERATION

SERVICE AREA Existing CPC/N No., if for renewal FILLING FEE


Subdivision :
a. Amount ____________
Barangay :
b. O. R. No. ___________
Provisional Authority Required
Municipality : c. Date ________________
Yes No
TYPE OF UTILITY NO. OF CONNECTIONS
[ ] Subdivision / HOA a. with water meters _____________________
[ ] Rural Water & Sanitation Association b. w/o water meters ______________________
[ ] Cooperative c. meter tested ____________________
[ ] Bulk Water Seller/Peddler c.1 tested by ____________________
[ ] Others ________________________ c.2 date tested ____________________
(specify) d. for bulk seller /peddler
Average volume of water delivered in cubic meters per day
________________________
KIND OF WATER SYSTEM
[ ] Draw & Fill [ ] Float [ ] Direct Pumping

LIST OF DOCUMENTARY REQUIREMENTS


NOTE: USE 5- YEAR TARIFF MODEL TO COMPLY ON
FINANCIAL REQUIREMENTS
( ) Articles of Incorporation/Partnership/ DTI Registration ( ) Latest Audited Financial Statement ¹
( ) Board resolution (for corporations and partnerships) or ( ) Actual Balance Sheet for Water Operations ¹‫׳‬²
special power of attorney (for single proprietorships) ( ) Actual Income Statement for Water Operations ¹‫׳‬²
authorizing the signatory to sign and file the application ( ) List of Existing Assets in Service Subject to Return ¹
( ) Copy of Approved Water Permit/s Itemized Projected Financial Statements for Water
( ) Copy of Official Receipt/s of Annual Water Charges Operations for 5 years
( ) Copy of Latest Certificate of Potability issued by ( ) Income Statements
City/Municipal Health Officer where source is located ( ) Funds Flow
with Results of Bacteriological, Physical & Chemical ( ) Balance Sheet
Impurities conducted by laboratory of DOH ( ) Assumptions
( ) Plan of Water Distribution System ( ) Business Plan & Itemized List of Required Investments
( ) Plan, Elevation of Cross-sectional Views of for the Next 5 yrs.
Tank/Reservoir ( ) Proposed Tariff Schedule
( ) Plan, Elevation of Cross-sectional Views of Pump House, ( ) Levels of service agreed with consumers commensurate
Machinery & Equipment with proposed rates
( ) Others
1 For new CPC applicants, last 2 years
For old applicants, last 2 years
2 If applicant has another operations other than water supply
I HEREBY CERTIFY THAT THE INFORMATION SUBSCRIBED AND SWORN TO BEFORE ME ON THIS
GIVEN ABOVE AND THE DOCUMENTS SUBMITTED DATE
ARE TRUE AND CORRECT TO THE BEST OF
KNOWLEDGE AND BELIEF

Signature of Water Utility Representative Notary Public / Administering Officer

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