Download - 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