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11-02 Application for Mineral Processing Permit

MGB application form for mineral processing permit

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

APPLICATION FOR MINERAL PROCESSING PERMIT
Application No. ___________________________

Date Filed ___________________

Applicant ______________________________________________________________
(Business Name of Individual, Corporation, Partnership)
Name of Responsible Corporate Official, Proprietor, Owner, Attorney-In-Fact
_______________________________________________________________________
Date of SEC Registration __________________________________________________
(If Corporation or Partnership)
Business Address ________________________________________________________
Civil Status _____________________________________________________________
Citizenship _____________________________________________________________
PLANT OPERATIONS :
Capacity _______________________________________________________________
Processes to be Employed _________________________________________________
(Please include flowsheet of planned operation)
Feed (Inputs) and Specifications ____________________________________________
Mineral Products and Specifications _________________________________________
_______________________________________________________________________

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
______________________________________________________.
(Business Name)
hereby applies for a Mineral Processing Permit.
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 permit 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 cancellation of the permit granted.

MGB Form No. 11-2

3. The applicant further binds himself to submit additional requirements should the
DENR Secretary or the Director of MGB Regional Office concerned deem if
necessary for purposes of determining his qualification for the permit applied for.
4. This application is filed for the exclusive use and benefit of the applicant and neither
directly nor 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 _______________, 19 ______.
_______________________
Applicant
T.I.N. _________________

ACKNOWLEDGEMENT

Republic of the Philippines
)
Province of _______________ )s.s.
City/Municipality of ________ )
Subscribed and sworn to before me that at the place aforesaid on this ________
day of _____________, 19_______., 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

___________
___________
___________
___________
 
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