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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