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PBQC Application Form Sample

This document is an application form for the Pangkabuhayang QC Program in Quezon City, Philippines. It collects personal information from applicants such as name, address, contact details, and information about how they have been affected by COVID-19 or recent typhoons. It asks if they were previous beneficiaries. It also gathers business-related information such as the type of business they want to start, number of employees, location, and required tools/equipment. Applicants must submit a proposed business plan with goals, details about the business, and a list of needed supplies.

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Sharlen Obial
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© © All Rights Reserved
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741 views4 pages

PBQC Application Form Sample

This document is an application form for the Pangkabuhayang QC Program in Quezon City, Philippines. It collects personal information from applicants such as name, address, contact details, and information about how they have been affected by COVID-19 or recent typhoons. It asks if they were previous beneficiaries. It also gathers business-related information such as the type of business they want to start, number of employees, location, and required tools/equipment. Applicants must submit a proposed business plan with goals, details about the business, and a list of needed supplies.

Uploaded by

Sharlen Obial
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
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PANGKABUHAYANG QC APPLICATION

FORM

m-_________
ID NO. OF VALID ID: STATUS OF CLIENT: IF UNEMPLOYED/RETIRED,
Displaced/Resigned/Reduced Salary Employee LAST EMPLOYMENT DATE:
Laid off OFW
Micro entrepreneur/ Vendors
Unemployed Solo Parent
PWD
Complete Name
MR./MS.

TITLE/PREFIX FIRSTNAME MIDDLENAME LASTNAME SUFFIX


Category of Potential Entrepreneur

Food (carinderia, restaurant, stall) Retail / Online Selling (clothes, accessories, products, etc.)
Logistics (delivery, transportation [FreeBis]) Urban Agriculture (JOUF, GrowQCseedling propagation, fertilizer production, aquaculture)
Sari-Sari Store Others, please specify:

Sex Civil Status Date of Birth (mm/dd/yy) Age


Male Female Single Widowed
Married Legally Separated
Address

House/BuildingNo./Room&FloorNo./BuildingName StreetName Barangay District

City/Municipality Province Region ZipCode


Living Condition Number of Persons in Household: Name of Spouse or Live-in Partner:
 Rent/ Lease Household
 Own House
 Living with parents or other
relatives
Name of Child/Children:

CONTACT DETAILS:

Telephone Number Mobile Number Email Address

I/We hereby declare and certify that I/we are the data subject and that I/we voluntary provided the Quezon City
Government the abovementioned information or data, which are true and correct to my/our knowledge, and that I/we
have complied with all laws and regulations governing the establishment, maintenance and operation of my/our
business.
I/We hereby further declare that I/we authorize or consent to the collection, recording, organization, storage, use and
processing of the data or information herein provided for the purpose of establishing a databank which shall be a source of all
information necessary for project monitoring, research and policy studies and informal dissemination campaigns as part of the
Pangkabuhayang QC program and mandated by RA 10173 – Data Privacy Act of 2012.

Right Thumbmark
For PWD

NAME AND SIGNATURE DATE


PANGKABUHAYANG QC
APPLICATION FORM

Complete Name
MR./MS.

TITLE/PREFIX FIRSTNAME MIDDLENAME LASTNAME SUFFIX

1. How have you been affected by the COVID-19 pandemic and other typhoons?
Paano po kayo naapektuhan ng pandemyang COVID-19 at mga bagyo?

o Not affected / Hindi naapektuhan


o Reduced salary / Kinaltasan ng suweldo
o Reduced day/s of work / Bawasangaraw ng may pasok
o Lost job or business / Nawalan ng trabaho o negosyo
o Laid-off from foreign employment (Laid-off OFWs) / OFW nanawalan ng trabaho
o Other, please specify:

2. Were you a beneficiary of the Pangkabuhayang QC (Phase 1) Program? Naging


benepisyaryo po ba kayo ng programang Pangkabuhayang QC (Phase 1)?

o Yes / Oo
o No / Hindi

3. Are you an employee of Quezon City Government? Ikaw ba ay isang kawani ng


Lungsod Quezon?

o Yes / Oo

What office? Anong opisina?: ___________________________________

Position/ Posisyon: _____________________________________

o No / Hindi

4. If your application were approved, would you be willing to undergo livelihood training
before receiving financial assistance?
Kung tanggapin ang inyong application, sasali po ba kayo sa livelihood training
bago makatanggap ng tulong pinansiyal?

o Yes / Oo
o No / Hindi

5. For MICROENTREPRENEURS/VENDORS, are you willing to apply for Mayor’s Permit


after receiving financial assistance? Para sa mga
MICROENTREPRENEURS/VENDORS, gusto po ba ninyong kumuha ng Mayor’s
Permit?

o Yes / Oo
o No / Hindi
MUNGKAHING PLANONG PANGNEGOSYO

I. PANGKALAHATANG IMPORMASYON (GENERAL INFORMATION)


A. Pangalan ng
Aplikante (Name of
the Applicant):
B. Tirahan (Address):

C. Edad (Age):

D. Kasarian (Gender)

II. LAYUNIN (GOAL)

A. Ano ang iyong layunin sa pagtatag ng negosyo? (What are your goals in
establishing business?)

III. MGA IMPORMASYON SA NEGOSYO (BUSINESS INFORMATION)

1. Bilang ng mga
empleyado
(Number of
employees):
2. Lokasyon ng
itatayong negosyo.
(Place of Business):
3. Kategoryang Food (carinderia, restaurant, stall) Retail / Online Selling
(clothes, accessories, products, etc.)
Nais Kuhanin
(Chosen Logistics (delivery, transportation [FreeBis]) Urban Agriculture
Category):
Sari-Sari Store Others, please specify:
IV. MGA KABAHAGI NG NEGOSYO (PARTS OF BUSINESS)

1. Mga Kinakailangang Kagamitan (Tools/Equipment):

BILANG UNIT URI/TYPE HALAGA NG KABUUANG


BAWAT ISA HALAGA

TOTAL:

Name/ Kind of Business: ______________________________________________________

INIHANDA NI (PREPARED BY): LAGDA (SIGNATURE):

CONTACT DETAILS:

VALIDATOR:

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