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. __________________________ Applicant Address Date Filed __________________ __________________________________________________________ __________________________________________________________

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 ___________________ Sir: 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. 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. 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. The foregoing statements are hereby certified to be true to the best of the

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MGB Form No. 08-3

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. All pertinent information required shall be given, inapplicable word canceled, and all blanks shall be filled up. Application not accompanied with all the required documents shall not be accepted.

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