applicant physical person

ពកយេស�ើរសអជា� បណ�ភា� កងរេសវកម�ពន�ដរ

APPLICATION FOR TAX AGENT LICENCE

១- ពកយេស�ើសអជា� បណ� េលខ Application No.:

២- សេណើ សថ� New Application សេណើ សបន� Renewed Application

របវន�បគ�លPhysical Person

នតបគ�ល/រក�មអជវកម�/សហរគាលឯកបគ�លLegal Person/Pass-through/Sole proprietorship៣- អ�កេស�ើស Applicant

របវន�បគ�ល Physical Person

អាសយដ�ាន �បកបអាជវកម� Business Address

នាមរតកល នង នាមខ�នName and surname

េភទSex

រប�សMale

រសFemale

ៃថ�ែខឆា� កេណើ តDate of birth

ស�� តNationality

េលខអត�ស�� ណបណ�Identification number

លខតឆ�ងែដនPassport number

អសយដ� នផ�ះេលខAddress No.

ផ�វStreet

ភមVillage

ឃ/សង� តខណ�Commune

រក�ង/រស�ក/ខណ�District

េខត�/រជធានProvince/City

សរេអឡករត�នកEmail

របអបសបរត/របអបសបរតេអឡករត�នកP.O. Box / Electronic mail box

ទរសព�ចលតMobile phone

ទរសព�េលើតO�ce telephone

ទរសរFax

ផ�ះេលខ/អគារHouse No./Building

ផ�វStreet

ភមVillage

ឃ/សង� តខណ�Commune

រក�ង/រស�ក/ខណ�District

េខត�/រជធានProvince/City

សរេអឡចរត�នកEmail

របអបសបរត/របអបសបរតេអឡចរត�នកP.O. Box / Electronic mail box

ទរសព�ចលតMobile Phone

ទរសព�េលើតO�ce telephone

ទរសរFax

ខ� បាទ/នាងខ� ជាអតតម�ន�ពន�ដរI am a former tax official

ខ� បាទ/នាងខ� ធា� បបានបេរមើករងរេននាយកដ� ន/សខពន�ដរI used to work for the department/tax branch of

អសរយៈេពលFor

ឆា� Years

ចបពៃថ�ែខឆា� Start date

ដលEnd date

អត�េលខម�ន�រជករOfficial ID No.

អត�េលខពន�ដរ Tax ID No.

តនាទមនចលនវត�ន Prior Retirement Title

គណេនយយករ នង សវនករជនាញែដលជាសមាជកវទយោស� នគណេនយយករ នងសវនករជនាញកម�ជាCertified Public Accountant and Audition who is the member of Kampuchea Institute of Certified Public Accountant and Auditions (KICPAA)

សមាជកភាពេលខMembership No.

កលបរេច�ទចលជាសមាជកDate of Admission D D M M Y Y Y Y

D D M M Y Y Y Y D D M M Y Y Y Y

របវន�បគ�លែដលបានរបឡងជាបជាភា� កងរេសវកម�ពន�ដរPhysical person who passed the Tax Agent exam

វ�� បនបរតប�� កករសកសោេលខCertificate No.

កលបរេច�ទេចញIssued Date D D M M Y Y Y Y

ទពរPage 1

D D M M Y Y Y Y

MINISTRY OF ECONOMY AND FINANCE

GENERAL DEPARTMENT OF TAXATION

KINGDOM OF CAMBODIA

NATION RELIGION KING

Signature or thumb print

Date

ហត�េលខ ឬស� មេមៃដ

េឈ� ះNameតនាទPositionេលខទរសព�Telephone No

/ Tax official use only

នាមករណសហរគាសែដលរត�វេស�ើសអជា� បណ�Name of Enterprise to be licensed

េលខអត�ស�� ណកម�សរេពើពន�Tax Identification Number (TIN)

កលបរេច�ទចះប�� ពន�ដរDate of Tax Registration D D M M Y Y Y Y

ផ�ះេលខ/អគារHouse No./Building

រទង រទយសហរគាសForm of Business

នតបគ�លLegal Person

រក�មអជវកម�/សហរគាលឯកបគ�លPass-through/Sole proprietorship

េផសងៗOthers

ទពរPage 2

របអបសមបរត/របអបសបរតេអឡករត�នកP.O. Box / Electronic mail box

ផ�វStreet

ភមVillage

ឃ/សង� តខណ�Commune

រក�ង/រស�ក/ខណ�District

េខត�/រជធានProvince/City

សរេអឡករត�នកEmail

ផ�ះេលខ/អគារHouse No./Building

ផ�វStreet

ភមVillage

ឃ/សង� តខណ�Commune

រក�ង/រស�ក/ខណ�District

េខត�/រជធានProvince/City

នាម នង េគាត�នាមName and surname

ឋនៈ / តនាទStatus / Title

ភាគហនកនកបShare (%)

វ�� បនបរតភា� កងរ/េសវកម�ពន�ដរេលខTax Agent Certificate No.

ទរសព�ចលតMobile phone

ទរសព�េលើតO�ce telephone

ទរសរFax

នតបគ�ល/រក�មអជវកម�/សហរគាសឯកបគ�ល Legal Person / Pass-Through / Sole Proprietorship

ពតមានស�ពនាយក បណា� ធករ ឬ កម�សទ�ករ Directors Managers of Owners detailេឈ� ះ នងអសយ ដ� ន មា� សភាគហន Name and Address Shareholder

អាសយដ�ាន �បកប អាជវកម� របសសហ�គាស Physical Address of Enterprise

%

ផ�ះេលខ/អគារHouse No./Building

ផ�វStreet

ភមVillage

ឃ/សង� តខណ�Commune

រក�ង/រស�ក/ខណ�District

េខត�/រជធានProvince/City

នាម នង េគាត�នាមName and surname

ឋនៈ / តនាទStatus / Title

ភាគហនកនកបShare (%)

វ�� បនបរតភា� កងរ/េសវកម�ពន�ដរេលខTax Agent Certificate No.

%

ផ�ះេលខ/អគារHouse No./Building

ផ�វStreet

ភមVillage

ឃ/សង� តខណ�Commune

រក�ង/រស�ក/ខណ�District

េខត�/រជធានProvince/City

នាម នង េគាត�នាមName and surname

ឋនៈ / តនាទStatus / Title

ភាគហនកនកបShare (%)

វ�� បនបរតភា� កងរ/េសវកម�ពន�ដរេលខTax Agent Certificate No.

%

កលបរេច�ទអជា� បណ�Date of Licence

D D M M Y Y Y Yអជា� បណ� េលខLicence No.

អជា� បណ� /នតបគ�ល/រក�មអជវកម�/សហរគាលឯកបគ�លែដលជាសមាជក ៃនវទយោស� នគណេនយយករ នង សវនករជនាញកម�ជាLicence/Legal person/Pass-through/Sole proprietorship who is the member of the Kampuchea Institute of Certified Public Accountants and Auditors

ខ� បាទ/នាងខ� Name

ឋនៈ/តនាទStatus / Title

ៃនសហរគាសខងេលើ សមរបកសថា ពតមានខងេលើ ពតជារតមរត�វ េហើយខ� បាទ/នាងខ� េស�ើសអជា� បណ� ភា� កងរេសវកម�ពន�ដរ។ ខ� បាទ/នាងខ� សមសនយោថានងមនជយេរជាមែរជង ឬផ�លេយាបលដលអ�កជាបពន�ឱយេគចេវះពន� ឬ បន�របាកពន�េឡើយ េទះបេដយផា� ល ឬេដយរបេយាល។of the above enterprise hereby declare that particulars given above are correct and I apply for the license of Tax Agent.I undertake not to directly or indirectly assist or advise taxpayers to evade or falsify taxes.

ខ� បាទ/នាងខ� សមទទលខសរត�វទងរស�ងចេពះមខចបោបទងឡាយ ជាធរមានរបសនមនអនវត�តមករសនយោខងេលើ។I am fully responsible due to the existing laws for any breaking the above undertaking. ហត�េលខ នង រត

(នតបគ�ល/រក�មអជវកម�/សហរគាសឯកបគ�ល)/ស� មេមៃដ (របវន�បគ�ល)Signature and Stamp (Legal person/Pass-through/Sole proprietorship)/Thumbprint (Physical person)

• វ�� បនបរតចះប�� េនរកសងពណជ�កម� MOC’s Registration Certificate (Legal Person/Pass-Through/Sole Proprietorship)

• លក�ន�កៈរក�មហន Memorandum and Article of Association (Legal Person/ Pass-Through/ Sole Proprietorship)

• វ�� បនបរតភា� កងរេសវកម�ពន�ដរ Tax Agent Certificate (Non-KICPAA’s Member)

• វ�� បនបរតប�� កសមាជកភាព ៃនវទយោស� នគណេនយយករជនាញ នងសវនករកម�ជា KICPAA’s Membership certificate

• លខតប�� កពទតងេធ�ើសកម�ភាពភា� កងរេសវកម�ពន�ដរ Business Confirmation

• វ�� បនបរតអករេលើតៃម�បែន�ម, បណ� បាតង ឬ ឯកសរប�� កបងពន� អករេផសងៗ VAT Certificate , Patent or Tax Payment Receipts

• លខតប�� កពអតតភាពករងរ (អតតម�ន�ពន�ដរ) Former Tax Official Confirmation (Former Tax Official)

• លខតប�� កថា មនែដលជាបពកពន�នងបទេល�ើសេផសងៗទកទងនងពន�ដរ ពអគ�នាយកដ� នពន�ដរ ឬ ពរកសងេសដ�កច� នងហរ�� វត� ឬ តលករ (អតតម�ន�ពន�ដរ) Tax Violation Confirmation from GDT , MEF or Court (Former Tax Official)

• លខតប�� កពករេគារពរបតបត�ចបោប នងបទបប��ត�នានាស�ពពន�ដរ (នតបគ�ល/ រក�មអជវកម�) Tax Compliance Confirmation (Legal Person/ Pass-Through)

៤- េសចក�របកស Declaration