PROVINCIAL GOVERNMENT OF ILOCOS NORTE

AE-MGCQ-FORM 1
APPLICATION FOR SPECIAL PERMIT TO OPERATE

This form is for the application for Special Permit to Operate an Accommodation Establishment in Ilocos Norte during the community quarantine. Please
provide all the information required. Use additional sheets if needed. This form is for free and can be reproduced.

ACCOMODATION LOCATION
ESTABLISHMENT
OWNER/ CONTACT
MANAGER NUMBER

PERMITS
( ) DOT Certificate of Authority to Operate ( ) Mayor’s / Business Permit ( ) DTI Permit

ESTABLISHMENT DETAILS ROOMS

Business Address A. Total B. Number of
Number of Rooms to be
Rooms Operated
Contact Number Total Room Total Room
Occupancy Occupancy
Email

ANCILLARY FACILITIES
INTENDED PURPOSE OF ACCOMMODATION Identify restaurants, swimming pools, gyms, spas, bars, activity
ESTABLISHMENT areas, function halls, and other ancillary facilities.
Only one purpose or guest classification is allowed. ANCILLARY FACILITY 50% CAPACITY
( ) Quarantining of OFWs and Returning Residents

( ) Accommodation of Authorised Persons Outside

Residence (APOR)
( ) Accommodation of Guests for Leisure

OWNER OR MANAGER’S STATEMENT AND CERTIFICATION

1. As the owner or manager of the Accomodation Establishment identified in this document, I am aware of the health protocols
being imposed by the Provincial Government of Ilocos Norte for the control of the COVID-19 pandemic and I understand the
conditions being imposed before I could operate the establishment.

2. I have read and I understand all the guidelines issued by the IATF and the Department of Tourism, particularly AO 2020-002 and
I hereby ensure that all these guidelines are followed in my Accommodation Establishment and all its ancillary facilities.
3. I shall allow the proper authorities to inspect the CCTV and conduct a physical inspection of the establishment to ensure
compliance to the foregoing conditions.

4. Should my establishment fail to follow guidelines, I hereby subject myself and the business to sanctions applicable under each
circumstance.

5. By affixing my signature on this document, I certify the truthfulness of the information I provided herein.

SIGNATURE

OWNER OR MANAGER

DATE OF SIGNATURE

FOR PGIN-INTO USE ONLY.

APPLICATION NUMBER DATE AND TIME DATE OF

RECEIVED INSPECTION