Republic of the Philippines s19

MGB Form No. 08-3

Republic of the Philippines PROVINCIAL/CITY MINING REGULATORY BOARD (P/CMRB) Province/City of ______

APPLICATION FOR QUARRY PERMIT

Application No. ______Date Filed ______Applicant ______Address ______Size of Applied Area (hectares)______Quarry Resources to be extracted/disposed ______Quantity ______

The Provincial Governor/City Mayor Provincial/City Mining Regulatory Board Province/City of ______

In accordance with the provisions of the Philippine Mining Act of 1995 and the Revised Implementing Rules and Regulations promulgated thereunder, the undersigned ______, for and in behalf of ______, hereby applies for a permit to extract and dispose ______materials from a tract of land situated in Sitio ______, Barangay ______, Municipality of ______, Province of ______, Island of ______, and bounded by:

On the North: ______

On the East: ______

On the South: ______

On the West: ______with an approximate area of ______hectares.

1. The application fee of ______has been paid under Official Receipt No. ______dated ______, Philippines.

2. The applicant agrees that the statements made in this application or made later in support hereof, shall be considered as conditions and essential parts of the Permit that may be granted by virtue thereof, and any falsehood in these statements or omission of facts which may later change, or affect substantially the facts set forth in said statements shall be sufficient cause for the cancellation of the permit granted.

3. 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 and the area is applied for the sole purpose of its development and operation, and for speculation.

1 MGB Form No. 08-3

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

I, ______, the person executing this affidavit for this application, being first duly sworn, depose and say: that I have read or have caused the foregoing application read to me; that I thoroughly understand the same; that each and every statement in this application is true and correct.

______Applicant TIN ______

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 ______

INSTRUCTION

1. This application shall be accomplished in quintuplicate, two copies to be retained by the applicant, the original and one copy to be forwarded to the Provincial/City Mining Regulatory Board, and the remaining copy for the files of the MGB Regional Office.

2. All pertinent information required shall be given, inapplicable word canceled, and all blanks shall be filled up.

3. Application not accompanied with all the required documents shall not be accepted.