LAGUNA LAKE DEVELOPMENT AUTHORITY

National Ecology Center, East Avenue

Diliman, Quezon City
Tel. Nos.: 8376-5430 Loc. 144; 8376-4067

APPLICATION FOR SHORELAND DEVELOPMENT CLEARANCE

APPLICANT'S INFORMATION
[ ] LGU [ ] INDIVIDUAL [ ] COOPERATIVE [ ] PRIVATE COMPANY
NAME OF APPLICANT

BUSINESS ADDRESS

TELEPHONE NO. FAX NO. E-MAIL

FOR INDIVIDUAL APPLICANTS ONLY

AGE CIVIL STATUS CITIZENSHIP DATE OF BIRTH PLACE OF BIRTH

NAME OF SP0USE (IF MARRIED) CITIZENSHIP DATE OF BIRTH PLACE OF BIRTH

RESIDENCE CERT. NO.

LOCATION/USE OF SHORELAND AREA

IS THE SHORELAND AREA APPLYING FOR TITLED? [ ] YES [ ] NO
IF YES:
LOCATION OF SHORELAND (COMPLETE ADDRESS) APPROXIMATE GEOGRAPHIC COORDINATES

LOT OWNER OCT NUMBER DATE ISSUED

TOTAL AREA TCT NUMBER DATE ISSUED

SPECIFY TYPE OF DEVELOPMENT

IF NO:
ADJOINING/ADJACENT STREET BARANGAY TOWN/CITY

PROVINCE APPROXIMATE AREA (IN SQUARE METERS) NOTE:

SUBJECT TO ACTUAL VERIFICATION

PURPOSE OF APPLICATION/TYPE OF DEVELOPMENT

APPLICANT'S AUTHORIZED REPRESENTATIVE

NAME OF AUTHORIZED REPRESENTATIVE

BUSINESS ADDRESS

TELEPHONE NO. FAX NO. E-MAIL

I do hereby certify the information supplied are true and correct in my knowledge and belief. I understand
that the information contained herein shall be subject to verification and that my false statements shall be
ground for rejection of this application.

_______________________________________________ ________________________________________________
Name & Signature of the Authorized Representative Name & Signature of the President/Owner

Date: _______________________ Date: _______________________

LLDA-CPD-Form 36 Issue Date: May 2015 Issue No.: 01