Annex B.
AFME Registration Application Form
Republic of the Philippines
Province of ____ ___
City/Municipality of ___ _ _
CITY/MUNICIPAL AGRICULTURAL AND FISHERIES MACHINERY & EQUIPMENT DATE OF APPLICATION (mm/dd/yyyy):
REGISTRATION OF OWNERSHIP APPLICATION FORM
TYPE OF REGISTRATION: Initial Registration Issuance of Amended Certificate of Registration (CAFMER)
OWNER REPRESENTATIVE OF ORGANIZATION/OFFICE ADDRESS OF OWNER/OFFICE/REPRESENTATIVE
NAME (Surname, First Name, Middle Name, Ext.) (Street/House No., Barangay, Municipality/City, Province)
BIRTHDATE OF OWNER/REPRESENTATIVE (mm/dd/yyyy): SEX: Male MOBILE NO. :
Female TELEPHONE NO. :
NAME OF ORGANIZATION/OFFICE (If owned by organization/office): POSITION OF REPRESENTATIVE:
--------------------------------- AGRICULTURAL AND FISHERIES MACHINERY AND EQUIPMENT FOR REGISTRATION ------------------------------
MACHINERY/ ATTACHMENTS /
SUPPLIER BRANCH ADDRESS
EQUIPMENT TYPE CAPACITY ACCESSORIES NAME OF SUPPLIER
(Street No., Barangay, Municipality/City, Province)
(Ref. Code) (Ref. Code)
1.
2.
3.
4.
5.
* Use another Application Form if number of machinery/equipment is more than 5 units.
YEAR MODE OF STATUS WHEN 3
BRAND SERIAL NUMBER USE OF FACILITY
ACQUIRED ACQUISITION 1 ACQUIRED 2
1.
2.
MACHINERY/
3.
EQUIPMENT
4.
5.
RATED
MAKE 4 5
POWER
1.
2.
PRIME MOVER
3.
4.
5.
AREA/S OF OPERATION APPLICATION NO.
(Province) (To be filled-out by the Registering Office)
1.
2.
MACHINERY/
3.
EQUIPMENT
4.
5.
Page 1 of 2 AFMEReg202008B
Annex B. AFME Registration Application Form
-------------------------------------------------------------- FOR CHANGE OF OWNERSHIP -----------------------------------------------------------------------
NAME OF PREVIOUS OWNER (Surname, First Name, Middle ADDRESS OF PREVIOUS OWNER (Street No., Barangay, Municipality/City, Province)
Name, Ext.)
-------------- FOR DELETION/CANCELLATION OF REGISTRATION OF AGRICULTURAL AND FISHERIES MACHINERY & EQUIPMENT -----------
REASONS FOR DELETION/CANCELLATION
Loss of Agricultural and Fisheries Machinery and Equipment
Transfer of Municipal/City
Others : _____________________________________________________
I HEREBY CERTIFY THAT ALL INFORMATION
CONTAINED HEREIN ARE TRUE AND CORRECT
Printed Name and Signature of Owner/Authorized Representative
Consent
I have read this form, understood its contents and consent to the processing of my personal data. I
understand that my consent does not prohibit the existence of other criteria for lawful processing of personal
data, and does not waive any of my rights under the Data Privacy Act of 2012 and other applicable laws.
Printed Name and Signature of Owner/Authorized Representative
FOR USE OF THE REGISTERING OFFICE ONLY. PLEASE DO NOT WRITE BELOW THIS LINE.
REMARKS, FINDINGS AND RECOMMENDATIONS
EVALUATED/RECOMMENDED BY: NOTED BY:
Chief, City/Municipal Agricultural Engineering Date City/Municipal Agriculturist Date
Division/Section
Legend/Notes:
1
– Mode of Acquisition : Cash, Grant (write the name of Grantor), Cost-sharing, Loan, Inherited, Donation
2
– Status When Acquired : BN (Brand New), SH (Second-hand)
3
– Use of Facility : PR (Private Use), CH (Custom Hire), PU (Public Use),
CA (Cooperative/Association Use), GV (Government Use), AU (Academic Use)
4
– Make : Prime Mover Country of Manufacture (e.g. Japan, China, etc.)
5
– Rated Power : hp, kW
Page 2 of 2 AFMEReg202008B
