Annex “A”

Republic of the Philippines

Department of Environment and Natural Resources
MINES AND GEOSCIENCES BUREAU
North Avenue, Diliman Quezon City

MINES AND GEOSCIENCES BUREAU

GEODETIC ENGINEER DEPUTATION INFORMATION SHEET

(DATE)

PHOTO
(2” x 2”)

Name:
Surname
First Name
Middle Name
Age:
Date of Birth:

Address:

Contact
Number/s:
E-Mail Address:

Educational Year
School/College/University
Background: Graduated
Primary
Secondary
College
Course
Professional
Regulation
Commision No.

1
 Present Employment
Current/Latest Project on
Mineral Land Surveys or
related activities

I, , the person executing this form, being first

duly sworn, depose and say: that I have read or have supplied the foregoing
information, that I thoroughly understand the same; that each and every
statement in same is true and correct.

Geodetic Engineer
PTR No.

SUBSCRIBED AND SWORN TO BEFORE ME, this day of

, 20 , affiant exhibiting his ,
, issued at on
, 20 .

NOTARY PUBLIC

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Page No.
Book No.
Series of