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06-1 Application for MPSA

MGB application form for mineral production sharing agreement

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Republic of the Philippines
Department of Environment and Natural Resources
MINES AND GEOSCIENCES BUREAU
Quezon City

APPLICATION FOR
MINERAL PRODUCTION SHARING AGREEMENT
Application No.:_____________
Applicant:
___________________________________________________________
Address:
___________________________________________________________
Business Phone No.: ______________________ Fax No:________________________
For Corporation, Partnership, Association or Cooperative:
Board of Directors and Officers:
Name
Position
_____________________________
______________________________
_____________________________
______________________________
_____________________________
______________________________
_____________________________
______________________________
_____________________________
______________________________
_____________________________
______________________________
Capitalization:
Authorized
Subscribed
Paid-Up

=
=
=

P_______________
P_______________
P_______________

Citizenship of Stockholders and Percentage of Holdings:
Nationality
Subscribed
Paid-Up
Filipino
____ %
_____ %
American
____ %
_____ %
Canadian
____ %
_____ %
Australian
____ %
_____ %
Others (pls. specify) _____ ____ %
_____ %
Mineral Commodity
________________________________________
Size of Area (hectares)
________________________________________
Location of Applied Area
________________________________________
(Please indicate the boundaries and/or the technical
description of the area in a separate sheet to be attached as
Annex “A” of this document)
In accordance with the provisions of the Philippine Mining Act of 1995 and
DENR Administrative Order No. 96-40 otherwise known as the Revised Implementing
Rules and Regulations promulgated thereunder, the undersigned, for and in behalf of
__________________________ hereby applies for a Mineral Production Sharing
Agreement to extract and dispose _________________ subject to the following
conditions:
1.

The statements made in this application or made later in support thereof, shall be
considered as conditions and essential parts of the Agreement that may be granted
and any or omission of facts which may alter, change, or affect substantially the
facts set forth in said statements shall be sufficient cause for the cancellation of
the granted.
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MGB Form No. 06-1

2.

The applicant further binds itself to submit additional requirements should the
Regional Director concerned deems necessary for purposes of determining his/her
qualification for the grant of the permit applied for.

3.

The 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 not for speculation.

4.

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

5.

The application fee of ________________________ had been paid under Official
Receipt No._______________ dated ____________________________ at
_________________________.

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

___________________________________
Applicant
TIN________________________________

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MGB Form No. 06-1

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. ________
Book No.________
Page No. ________
Series of ________

INSTRUCTION
1.

This application shall be accomplished in quintuplicate, two copies to be retained
by the applicant, one copy to be retained by the MGB Regional Office and the
remaining copies to be forwarded to the MGB Central Office.

2.

All pertinent information required shall be given, inapplicable words cancelled
and all blanks shall be filled up.

3.

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

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