APPLICATION FORM FOR POLYMER EXEMPTION

FROM PMPIN PROCEDURES

1. Type of Application Confidential Not Confidential

2. Information of Applicant

Name of Company (Philippine Company): ______________________________________

Company Address: ______________________________________
______________________________________
Contact Person: ______________________________________
Email Address: ______________________________________
Telephone: ______________________________________
Fax: ______________________________________

3. Polymer Information

Chemical Name: ______________________________________

CAS Number : ______________________________________
Product or Trade Name: ______________________________________
Use: ______________________________________

4. Monomer Information

Percentage by Listed on
Chemical Name CAS Number
Weight PICCS? (Y/N)

5. List of Attachment

6. Signature over Name of Applicant

__________________________________ _____________________________
Name of Applicant Position

7. Notarization

SUBCRIBE and SWORN before me, a Notary Public; this ______ day of _____________, affiant
exhibiting to me this Community Tax Receipt:

Name CTR No. Issued at Issued on

____________________ ______________ ____________________ _________________
____________________ ______________ ____________________ _________________

_____________________
Notary Public
Doc No: ___________
Page No: ___________
Book No: ___________
Series of: ___________