OFFICE OF THE GOVERNOR PROVINCE OF CEBU ANNEX ‘A APPLICATION FOR QUARRY MINING/PLANNING AND SLUICING/GUANO PERMIT TO EXTRACT AND DISPOSE OF MINERAL/QUARRY RESOURCES NO. DATE FILED APPLICANT, (Individual, Corporation, Partnership) DATE OF REGISTRATION (If corporation or partnership) ADDRESS STATUS CITIZENSHIP _ NAME OF ASSIGMENT _ (if being filed by an assignee) DATE OF ASSIGMENT AND RECORDING NAME OF CLAIMOWNER (if being filed by the operator) DATES OF OPERATING CONTRACT AND RECORDING IDENTITY OF MINING CLAIMS OR QUARRY PERMIT/APPLICATION (if being filed under par: (a) & (b) Of Sec. 7) SIZE OF AREA LOCATION KIND OF MATERIAL COMMODITY QUANTITYoi ‘n accordance with the provision of Provincial Ordinance No. 2008-10 and the rules and regulations promulgated hereunder, the undersigned citizen of the. for the behalf applies for. permit to extract mineral/quarry resources for commercial purposes on the areas described hereunder (Please Sketch the boundaries and/or technical description of the area and attached the corresponding sketch/survey plan). . The application agrees that the statement made in the application or made letter in support thereof, shall be considered as conditions and essential parts of the permit that may be granted by virtue thereof and any falsehood statements 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 permit granted. The application further agrees to submit additional requirements should the Regional Director concemed deem if necessary for the purpose of determining the qualification, for the grant of the permit applied for. This application is filed for the exclusive use of and benefit of the applicant and not either directly or indirectly for the benefit if any other person, corporation of partnership and the land is applied for the sole purpose of its development and operation, and no for speculation. In case of conflict, the application is willing to file a bond with the Mines and Geo-Science Bureau in such amount and subject to such terms and conditions as the Director of Mines and Geo-Sciences may prescribe, before the grant of the permit applied for. The foregoing statements are hereby certified to be true to the best of the applicant's knowledge and belief. The Applicant Fee of P had been paid under Official Receipt No.. Dated. 20___ Phillippines.REPUBLIC OF THE PHILIPPINES) PROVINCE OF CEBU S.S. CITY/MUNICIPALITY the person executing this eer ey depose and say, that | have read ‘or have caused the foregoing application to be read to me, that |, thoroughly understand the same, that each and every statement in said application is tue and correct. Affiant T.AN. SUBSCRIBED AND SWORN to before me at the place aforesaid, on this ___ day of________—_.-:‘The_affiant exhibited to me his/her Residence Certificate No___......-——~—=—~=____— issued at on the. day of NOTARY PUBLIC My commission expires on Dec. 31 PTR No. SERIES OF:__ INSTRUCTIONS 1. This application shall be accomplished | quintuplicate, two carbon copies to be retained by the applicant one carbon copy to be forwarded to the Manila Office and remaining carbon copies for the Mines and Geo-Sciences Office. 2. All pertinent Information required shall be given, inapplicable words cancelled, and all blanks shall be filed up. 3. Application not accomplished with all the required documents shall not be accepted.BIO DATA (Geen) sie) wena) ‘wnceney Date of Birth Pace of Birth __Citzenship Wiig kg. ‘Year Groduates High Schoo - _ College _ - Honors/Award/Citaton 1D. EMPLOYMENT RECORD (Irom past to present) Indusive Dates ‘Name of Fim Designation I HEREBY DECLARE THAT ALL THE FOREGOING STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE ener Te No ‘send SSSIGSEE ‘SUBSCRIBED AND SWORN to before me tis day of 20 Doe No Book No, Sores of