applicant physical person
TRANSCRIPT
αααααοΏ½αΎααα’ααΆοΏ½ ααοΏ½ααΆοΏ½ ααααααααοΏ½ααοΏ½αα
APPLICATION FOR TAX AGENT LICENCE
α‘- αααααοΏ½αΎαα’ααΆοΏ½ ααοΏ½ ααα Application No.:
α’- ααααΎ ααοΏ½ New Application ααααΎ αααοΏ½ Renewed Application
ααααοΏ½ααοΏ½αPhysical Person
ααααοΏ½α/ααοΏ½αα’ααααοΏ½/αα αααΆαα―αααοΏ½αLegal Person/Pass-through/Sole proprietorshipα£- α’οΏ½αααοΏ½αΎα Applicant
ααααοΏ½ααοΏ½α Physical Person
α’αΆαααοΏ½αΆα οΏ½αααα’αΆααααοΏ½ Business Address
ααΆααααα αα ααΆααοΏ½αName and surname
αααSex
ααοΏ½αMale
ααFemale
ααοΏ½ααααΆοΏ½ ααααΎ αDate of birth
αοΏ½οΏ½ αNationality
αααα’αοΏ½αοΏ½οΏ½ αααοΏ½Identification number
ααααοΏ½ααααPassport number
α’αααοΏ½ ααοΏ½ααααAddress No.
αοΏ½αStreet
ααVillage
α/ααοΏ½ αααοΏ½Commune
ααοΏ½α/ααοΏ½α/ααοΏ½District
αααοΏ½/ααααΆαProvince/City
αααα’α‘αααοΏ½ααEmail
ααα’ααααα/ααα’ααααααα’α‘αααοΏ½ααP.O. Box / Electronic mail box
ααααοΏ½α ααMobile phone
ααααοΏ½αααΎαOοΏ½ce telephone
ααααFax
αοΏ½αααα/α’ααΆαHouse No./Building
αοΏ½αStreet
ααVillage
α/ααοΏ½ αααοΏ½Commune
ααοΏ½α/ααοΏ½α/ααοΏ½District
αααοΏ½/ααααΆαProvince/City
αααα’α‘α ααοΏ½ααEmail
ααα’ααααα/ααα’ααααααα’α‘α ααοΏ½ααP.O. Box / Electronic mail box
ααααοΏ½α ααMobile Phone
ααααοΏ½αααΎαOοΏ½ce telephone
ααααFax
αοΏ½ ααΆα/ααΆααοΏ½ ααΆα’αααοΏ½αοΏ½ααοΏ½ααI am a former tax official
αοΏ½ ααΆα/ααΆααοΏ½ ααΆοΏ½ αααΆααααααΎααααααααΆαααοΏ½ α/ααααοΏ½ααI used to work for the department/tax branch of
α’αααααααFor
ααΆοΏ½ Years
α ααααοΏ½ααααΆοΏ½ Start date
ααEnd date
α’αοΏ½ααααοΏ½αοΏ½ααααOfficial ID No.
α’αοΏ½αααααοΏ½αα Tax ID No.
αααΆαααα ααααοΏ½α Prior Retirement Title
αααααααα αα ααααααααΆααααααΆαααΆαααααααοΏ½ ααααααααα ααααααααααΆαααοΏ½ααΆCertified Public Accountant and Audition who is the member of Kampuchea Institute of Certified Public Accountant and Auditions (KICPAA)
αααΆααααΆααααMembership No.
αααααα οΏ½αα αααΆαααΆααDate 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
ααααοΏ½ααοΏ½ααααααΆαααα‘αααΆαααΆααΆοΏ½ ααααααααοΏ½ααοΏ½ααPhysical person who passed the Tax Agent exam
αοΏ½οΏ½ ααααααοΏ½οΏ½ ααααααααααCertificate No.
αααααα οΏ½ααα αIssued Date D D M M Y Y Y Y
αααPage 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
α αοΏ½ααα α¬αοΏ½ ααααα
ααοΏ½ αNameαααΆαPositionαααααααοΏ½Telephone No
/ Tax official use only
ααΆαααααα αααΆααααααοΏ½αααοΏ½αΎαα’ααΆοΏ½ ααοΏ½Name of Enterprise to be licensed
αααα’αοΏ½αοΏ½οΏ½ αααοΏ½αααααΎααοΏ½Tax Identification Number (TIN)
αααααα οΏ½αα ααοΏ½οΏ½ ααοΏ½ααDate of Tax Registration D D M M Y Y Y Y
αοΏ½αααα/α’ααΆαHouse No./Building
ααα ααααα αααΆαForm of Business
ααααοΏ½αLegal Person
ααοΏ½αα’ααααοΏ½/αα αααΆαα―αααοΏ½αPass-through/Sole proprietorship
αααααOthers
αααPage 2
ααα’αααααα/ααα’ααααααα’α‘αααοΏ½ααP.O. Box / Electronic mail box
αοΏ½αStreet
ααVillage
α/ααοΏ½ αααοΏ½Commune
ααοΏ½α/ααοΏ½α/ααοΏ½District
αααοΏ½/ααααΆαProvince/City
αααα’α‘αααοΏ½ααEmail
αοΏ½αααα/α’ααΆαHouse No./Building
αοΏ½αStreet
ααVillage
α/ααοΏ½ αααοΏ½Commune
ααοΏ½α/ααοΏ½α/ααοΏ½District
αααοΏ½/ααααΆαProvince/City
ααΆα αα αααΆαοΏ½ααΆαName and surname
ααα / αααΆαStatus / Title
ααΆαα αααααShare (%)
αοΏ½οΏ½ αααααααΆοΏ½ ααα/αααααοΏ½ααοΏ½αααααTax Agent Certificate No.
ααααοΏ½α ααMobile phone
ααααοΏ½αααΎαOοΏ½ce telephone
ααααFax
ααααοΏ½α/ααοΏ½αα’ααααοΏ½/αα αααΆαα―αααοΏ½α Legal Person / Pass-Through / Sole Proprietorship
ααααΆααοΏ½αααΆαα αααΆοΏ½ ααα α¬ ααοΏ½ααοΏ½αα Directors Managers of Owners detailααοΏ½ α ααα’αα αοΏ½ α ααΆοΏ½ αααΆαα α Name and Address Shareholder
α’αΆαααοΏ½αΆα οΏ½ααα α’αΆααααοΏ½ ααααα οΏ½ααΆα Physical Address of Enterprise
%
αοΏ½αααα/α’ααΆαHouse No./Building
αοΏ½αStreet
ααVillage
α/ααοΏ½ αααοΏ½Commune
ααοΏ½α/ααοΏ½α/ααοΏ½District
αααοΏ½/ααααΆαProvince/City
ααΆα αα αααΆαοΏ½ααΆαName and surname
ααα / αααΆαStatus / Title
ααΆαα αααααShare (%)
αοΏ½οΏ½ αααααααΆοΏ½ ααα/αααααοΏ½ααοΏ½αααααTax Agent Certificate No.
%
αοΏ½αααα/α’ααΆαHouse No./Building
αοΏ½αStreet
ααVillage
α/ααοΏ½ αααοΏ½Commune
ααοΏ½α/ααοΏ½α/ααοΏ½District
αααοΏ½/ααααΆαProvince/City
ααΆα αα αααΆαοΏ½ααΆαName and surname
ααα / αααΆαStatus / Title
ααΆαα αααααShare (%)
αοΏ½οΏ½ αααααααΆοΏ½ ααα/αααααοΏ½ααοΏ½αααααTax Agent Certificate No.
%
αααααα οΏ½αα’ααΆοΏ½ ααοΏ½Date of Licence
D D M M Y Y Y Yα’ααΆοΏ½ ααοΏ½ αααLicence No.
α’ααΆοΏ½ ααοΏ½ /ααααοΏ½α/ααοΏ½αα’ααααοΏ½/αα αααΆαα―αααοΏ½ααααααΆαααΆαα αααααααοΏ½ ααααααααα αα ααααααααΆαααοΏ½ααΆLicence/Legal person/Pass-through/Sole proprietorship who is the member of the Kampuchea Institute of Certified Public Accountants and Auditors
αοΏ½ ααΆα/ααΆααοΏ½ Name
ααα/αααΆαStatus / Title
αααα αααΆααααααΎ ααααααααΆ ααααΆααααααΎ ααααΆαααααοΏ½α αα αΎααοΏ½ ααΆα/ααΆααοΏ½ ααοΏ½αΎαα’ααΆοΏ½ ααοΏ½ ααΆοΏ½ ααααααααοΏ½ααοΏ½ααα αοΏ½ ααΆα/ααΆααοΏ½ ααααααααΆααααααααααΆααααα α¬αοΏ½ααααΆααααα’οΏ½αααΆαααοΏ½α±αααα αααααοΏ½ α¬ ααοΏ½αααΆαααοΏ½αα‘αΎα αααααααααΆοΏ½ α α¬ααααααααΆααof 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.
αοΏ½ ααΆα/ααΆααοΏ½ αααααααααοΏ½αααααοΏ½αα αααααα αααααα‘αΆα ααΆααααΆαααααααα’αααοΏ½αααααααααααααΎαI am fully responsible due to the existing laws for any breaking the above undertaking. α αοΏ½ααα αα αα
(ααααοΏ½α/ααοΏ½αα’ααααοΏ½/αα αααΆαα―αααοΏ½α)/αοΏ½ ααααα (ααααοΏ½ααοΏ½α)Signature and Stamp (Legal person/Pass-through/Sole proprietorship)/Thumbprint (Physical person)
β’ αοΏ½οΏ½ αααααα ααοΏ½οΏ½ αααααααααοΏ½ααοΏ½ MOCβs Registration Certificate (Legal Person/Pass-Through/Sole Proprietorship)
β’ ααοΏ½αοΏ½ααααοΏ½αα α Memorandum and Article of Association (Legal Person/ Pass-Through/ Sole Proprietorship)
β’ αοΏ½οΏ½ αααααααΆοΏ½ ααααααααοΏ½ααοΏ½αα Tax Agent Certificate (Non-KICPAAβs Member)
β’ αοΏ½οΏ½ ααααααοΏ½οΏ½ ααααΆααααΆα αααααααοΏ½ ααααααααααααΆα αααααααααοΏ½ααΆ KICPAAβs Membership certificate
β’ ααααοΏ½οΏ½ αααααααοΏ½αΎαααοΏ½ααΆαααΆοΏ½ ααααααααοΏ½ααοΏ½αα Business Confirmation
β’ αοΏ½οΏ½ αααααα’αααααΎαααοΏ½αααοΏ½α, ααοΏ½ ααΆαα α¬ α―ααααοΏ½οΏ½ αααααοΏ½ α’ααααααα VAT Certificate , Patent or Tax Payment Receipts
β’ ααααοΏ½οΏ½ ααα’ααααΆααααα (α’αααοΏ½αοΏ½ααοΏ½αα) Former Tax Official Confirmation (Former Tax Official)
β’ ααααοΏ½οΏ½ αααΆ αααααααΆαααααοΏ½ααααααοΏ½αΎααααααααααααααοΏ½αα αα’αοΏ½ααΆαααοΏ½ αααοΏ½αα α¬ ααααααααοΏ½αα οΏ½ ααα αοΏ½οΏ½ ααοΏ½ α¬ αααα (α’αααοΏ½αοΏ½ααοΏ½αα) Tax Violation Confirmation from GDT , MEF or Court (Former Tax Official)
β’ ααααοΏ½οΏ½ αααααααΆαααααααοΏ½α ααα ααααααοΏ½οΏ½αοΏ½ααΆααΆαοΏ½αααοΏ½αα (ααααοΏ½α/ ααοΏ½αα’ααααοΏ½) Tax Compliance Confirmation (Legal Person/ Pass-Through)
α€- ααα αοΏ½αααα Declaration