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05-1 Application for Exploration Permit

MGB application form for exploration permit

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REVISED
REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
MINES AND GEOSCIENCES BUREAU
QUEZON CITY
APPLICATION FOR SMALL SCALE MINING PERMIT TO CONTRACT
AND DISPOSE OF MINERAL RESOURCES

NUMBER:

DATE FILED:

TIME FILED:

FILED AT THE:
NAME OF RESERVATION:
MINERAL COMMODITY APPLIED FOR:

SIZE OF AREA:
(Hectares)

EXPECTED MONTHLY PRODUCTION
(Metric Tons)

SURVEYED BY:

SITIO:

BARANGAY:

MUNICIPALITY:

DATE SURVEYED:

PROVINCE:

NAME OF APPLICANT:
RESIDENCE:
MAILING ADDRESS:
DATE OF BIRTH:

SEX:

CIVIL STATUS:

CITIZENSHIP:

IF MARRIED.
NAME OF SPOUSE:
IF PARTNERSHIP, CORPORATION
ASSOCIATION OF COOPERATIVE: NAME
SITUS/PLACE OF OPERATION:
DATE OF REGISTRATION:

LIFE:

NAME OF PERSON(S) WHO WILL ACT AS LIAISON:
1. In accordance with the provision of Republic Act No. 7942 and its implementing rules and regulations
and other related laws, the undersigned _____________________________________________for and in behalf of
______________________________by virtue of the attached duly notarized Special Power of Attorney or Board
Resolution, as the case may be, hereby applies for a SMALL SCALE MINING PERMIT to extract the above
stated mineral commodity for commercial purposes on the area described. (Please state the boundaries and/or
technical description on the attached corresponding survey plan).

2. The application fee of P _________________ and the occupation fee of P ____________ for the first
calendar year have been paid under Official Receipt No. ____________________ dated ____________, 19_______,
Philippines.
3. This application is filed for the exclusive use and benefit of the applicant and neither directly or
indirectly for the benefit of any person, corporation, partnership, association or cooperative and the area mineralized
and not applied for speculation purposes.
4. The applicant agrees (in case of gold production) that all gold produced from the permit area shall be
sold to the Bangko Sentral ng pilipinas or its authorized representatives.
5. The applicant also agrees to submit additional requirements should the Mines and Geosciences Bureau
Director deem it necessary for the purpose of determining his qualification for the grant of the permit applied for.
6. The applicant further agrees that the statements made in the application or made later in support thereof,
shall be considered as conditions and essential parts of the permit that maybe granted by virtue thereof and any
falsehood in these statements or omission of facts which may alter, change or effect substantially the facts set forth
in said statements shall be sufficient cause for the denial of this application or cancellation of the permit granted.

Republic of the Philippines)
Province ______________) S.S>
City/Municipality_______)
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 and that each every statement in said application is true and correct.

_____________________________
Affiant/Applicant
T.A.N. _______________________
SUBCRIBED AND SWORN to before me at the place aforesaid on this ____________ day of
___________, 19 ______, the affiant/applicant exhibited to me his/her Residence Certificate No. _______________
issued at ___________________ on _________________ day of _______________, 19____________.

NOTARY PUBLIC
My commission expires on December 31, 19 _______
PTR No. ____________________________________
DOC NO. _____________:
PAGE NO. ____________:
BOOK NO. ____________:
SERIES OF ____________:
 
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