MGB FORM NO 131 REPUBLIC OF THE PHILIPPINES DEPARTMENT

FOR CANDOR • DRYDEN • GEORGE JUNIOR REPUBLIC
VELEPOSLANIŠTVO REPUBLIKE SLOVENIJE EMBASSY OF THE REPUBLIC OF
(DÁLE TÉŽ JEN „OBJEDNÁVKA“) TMOBILE CZECH REPUBLIC AS TOMÍČKOVA

(TRANSLATION) POSITION PAPER OF THE PEOPLE’S REPUBLIC OF CHINA
+REPUBLICA BOLIVARIANA DE VENEZUELA UNIVERSIDAD DE ORIENTE NUCLEO DE
0 REPUBLIC OF SOUTH AFRICA CANVAS 2 IN THE

MGB Form No. 13-1

Republic of the Philippines

Department of Environment and Natural Resources

MINES AND GEOSCIENCES BUREAU

North Avenue, Diliman, Quezon City



APPLICATION FOR

ACCREDITATION AS DEALER, TRADER, OR RETAILER OF MINERALS/MINERAL PRODUCTS AND/OR

BY-PRODUCTS


Application No. _____________________ Date Filed _________________________


Applicant ______________________________________________________________

(Business Name of Individual, Corporation, Partnership)


Name of Responsible Corporate Official, Proprietor, Owner, Attorney-In- Fact

_______________________________________________________________________


Date of Registration ______________________________________________________

(If Corporation or Partnership)


Business Address _________________________________________________________


Citizenship ______________________________________________________________


Mineral/s, Mineral Product/s and By-products


________________________________________________________________________



Name/s of Supplier/s Address Permit/Lessee/Contract No.


a. ______________________________________________________________________

b. ______________________________________________________________________

c. ______________________________________________________________________

d. ______________________________________________________________________

e. ______________________________________________________________________

(Use back page if space is not enough)



1. In accordance with the provisions of the DENR Administrative Order No. 96-40 or the revised Implementing Rules and Regulations of RA No. 7942, the undersigned citizen of the ________________________________________ for and in behalf of _____________________________________________________ hereby (Business Name)

applies for accreditation as a Dealer, Trader and/or Retailer of minerals/mineral products/by-products enumerated or described above.


2. The applicant agrees that the statements made in the application or made later in support hereof, shall be considered as conditions and essential parts of the accreditations that may be granted by virtue thereof and any falsehood in these statements or omissions of facts which may later change, or effect substantially the facts set forth in said statements shall be sufficient ground for the nullification of the accreditation granted.


3. The applicant further agrees to submit additional requirements should the DENR SECRETARY, DIRECTOR or MINES REGIONAL DIRECTOR deem necessary for purposes of determining his qualification for the accreditation applied for.


4. This application is filed for the exclusive use and benefit of the applicant and not either directly or indirectly for the benefit of any other person. corporation or partnership.


5. The foregoing statements are hereby certified to be true to the best of the applicant's knowledge and belief.


6. An application fee of P ______________ has been paid under Official Receipt No. _________________ dated _______________, 199______.




________________________

Applicant

T.I.N. __________________



ACKNOWLEDGEMENT


Republic of the Philippines _____ )

Province of ________________ ) S. S.

City/Municipality of __________ )


SUBSCRIBED AND SWORN to before me at the place aforesaid, on this __________ day of ____________________, 19_____. The affiant exhibited to me his/her Community Tax Certificate No. ____________ issued at ___________ on the ___________ day of _______________, 19____.

___________________________

NOTARY PUBLIC

Until Dec. 31, 19 ______

PTR No. ____________

Doc. No. _______

Page No. _______

Book No. _______

Series of _______












0 REPUBLICA DE CHILE MINISTERIO DE DEFENSA NACIONAL SUBSECRETARIA
0 REPUBLICA DE CHILE MINISTERIO DE SALUD DPTO ASESORIA
03211 REPUBLIKA E KOSOVËS REPUBLIKA KOSOVA REPUBLIC OF


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