Professional Documents
Culture Documents
In accordance with the provisions of the Philippines Mining Act of 1995 and the Revised Rules and
Regulations, promulgated thereunder, the undersigned, for and in behalf of the abovecited company
hereby applies for a Certification of Environmental Management and Community Relations Record
subject to the following conditions:
1. The Statements made in his application or made later in support thereof, shall be considered as
conditions and essential parts of the agreement that may be granted by virtue thereof and any
falsehood or omission of facts which may alter, change, or effect substantially the facts set forth in
said statements shall be sufficient cause for the cancellation of the granted.
2. The applicant further agrees to submit additional requirements that the Regional Director
concerned deems necessary for purposes of determining his/her qualification for the grant of the
Certification 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.
4. The foregoing statements are hereby certified to be true to the best of the applicant’s knowledge
and belief.
_____________________________________
Applicant
TIN _________________________________
ACKNOWLEDGEMENT
_____________________________
NOTARY PUBLIC
Until Dec. 31, ________
PTR No. ____________
---------------------------------------------------------------------------------------------------------------------------
INSTRUCTION
1. This application shall be accomplished in triplicate, one copy to be retained by the applicant
and the remaining copies to be submitted to the Bureau.
2. All pertinent information required shall be given, inapplicable words cancelled and all blanks
shall be filled up.