MGB Form No.

07-1

Republic of the Philippines

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

APPLICATION FOR
FINANCIAL OR TECHNICAL ASSISTANCE AGREEMENT

Application No. : __________________

Name of Corporation : _______________________________________________
_______________________________________________
Address : _______________________________________________
_______________________________________________
Telephone No. : _______________________________________________
Facsimile No. : _______________________________________________

Date of SEC Registration : _______________________________________________

Corporate Profile :
Board of Directors and Officers:
Name
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
Position
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________

Capitalization
Authorized : ___________________
Subscribed : ___________________
Paid-Up : ___________________

Citizenship of Stockholders and Percentage of Holdings

Nationality Subscribed Paid-up
Filipino ________% _______%
American ________% _______%
Canadian ________% _______%
Australina ________% _______%
Others, pls. specify)_________ ________% _______%

Mineral Commodity : ____________________________________

Size of Applied Area (Hectares) : ____________________________________
Location of Applied Area : ____________________________________
____________________________________

(Please indicate technical description of the area and attach the

corresponding sketch/survey plan)

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MGB Form No. 07-1

In accordance with the provisions of the Philippine Mining Act of 1995 and
DENR Administrative Order No. 96-40, otherwise known as the Revised Implementing
Rules and Regulations promulgated thereunder, the undersigned, for and in behalf of
_______________________ hereby applies for a Financial or Technical Assistance
Agreement for the exploration, development and utilization of mineral resources for
commercial purposes on the areas described herein, subject to the following:

1. The applicant agrees that the statements made in the application or made later in
support thereof, shall be considered as conditions and essential parts of the permit
that may be granted by virtue thereof and any falsehood in these 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.

2. The applicant further agrees to submit additional requirements should the

Secretary/Director/Regional Director concerned deems necessary for purposes of
determining his/her qualifications before the grant of the contract 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 and the area is for the sole purpose of its development and operation,
and not for speculation.

4. The foregoing statements are hereby certified to be true to the best of the
applicants knowledge and belief.

6. The application fee of __________ had been paid under Official Receipt No.
____________ dated ____________ at ____________________.

I _________________________, the person executing this application, being

first sworn, depose and say: That I have read or have caused the foregoing application to
be read to me; That I thoroughly understand the same; That each and every statement in
said application is true and correct.

____________________________
Applicant
TIN ________________________

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MGB Form No. 07-1

ACKNOWLEDGEMENT

Republic of the Philippines __________ )

Province of _______________________ ) s.s.
City/Municipality of _______________ )

SUBSCRIBED AND SWORN to before me at the place aforesaid, on this

__________ day of _____________, 19____. The affiant exhibited to me his/her
Community Tax Certificate No. _____________ issued at ____________ on the _______
day of ______________, 19____.

______________________________
NOTARY PUBLIC
Until Dec. 31, 19______
PTR No. ____________

Doc. No. ______

Page No. ______
Book No.______
Series of ______

INSTRUCTION

1. This application shall be accomplished in quintuplicate, two copies to be retained by

the applicant, one copy to be forwarded to the MGB Central Office and the remaining
copies for the MGB Regional Office.

2. All pertinent information required shall be given, inapplicable words, cancelled and
all blanks shall be filled up.

3. Application not accompanied with all the required documents shall not be accepted.