MGB Form No.

15-1

Republic of the Philippines

Department of Environment and Natural Resources
MINES AND GEOSCIENCES BUREAU
Regional Office No. ______

PERMANENT SAFETY ENGINEER’S PERMIT

This is to certify that the application of    _________________________________

to act as Permanent Safety Engineer per recommendation of the General Superintendent

in a communication dated    ___________________    to this Office has been duly noted

and approved. He is, therefore, hereby permitted to practice as such only while in the

employ of ______________________________________________________________

pursuant to the provisions of the Philippine Mining Act of 1995 and the revised

Implementing Rules and Regulations promulgated thereunder and Mines Administrative

Order No. MRD 51, Series of 1991, otherwise known as the Revised Mine Safety Rules

and Regulations.

Given under the seal of this Bureau at ______________, Philippines, this,

_______ day of __________________    ,    _________.

REGIONAL DIRECTOR

        DRY SEAL

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