Department of Environment and Natural Resources

Environmental Management Bureau Region 2

Please attach your
2” x 2” picture here
Pollution Control Officer Revision No. 1
(PCO) Accreditation Application Form Page 1 of 3
(New/Renewal)
Instructions:
Fill in all the data needed. If the blanks are not applicable, write N.A.
PROFILE
Last Name First Name Middle Name Sex: Citizenship:
Male
Female
Home Address (Number & Street, Town/City, Employment Current Position:
Province, Zip Code) Status:
Full-time No. of Years in
Current Position:
Part-time
Effectivity of Appointment as
Others PCO:

Telephone No.: Cellular Phone No.: E-mail Address:

ACCREDITATION INFORMATION
Project Name / Establishment Name: Name of Managing Head:

Position:

Project Location Address (Number & Street, Nature of Establishment Category based
Town/City, Province, Zip Code) Business of the on DAO 2014-02:
Establishment:

Telephone No.: Fax No.: Website:

✓ QUANTITY & CLASSIFICATION:

Handling / Storing Chemicals Listed
in Annex 1 of DAO 2014-02
Hazardous Waste Generated:

With Centralized MRF / Sanitary

Landfill:
Generator Set / Boiler Capacity (Kw /
KvA / Hp):
Waste water discharged (cu.m/day):

Transporter / Treater of Sludge:

Other Sources of pollution:

EMB-R02-FM-CPD-PCO-019 00 08-14-19
 Department of Environment and Natural Resources
Environmental Management Bureau Region 2

Pollution Control Officer Revision No. 1

(PCO) Accreditation Application Form Page 2 of 3
(New/Renewal)
HIGHEST EDUCATIONAL ATTAINMENT
School Address Inclusive Degree/Units Earned
Dates

Type of PRC License received (if any):

PRC License No.: Date Issued: Validity:

WORK EXPERIENCE (Use additional sheet if necessary. Please attach photocopy of Certificate of
Employment)
Status of Employment
Company Position Inclusive Dates

ENVIRONMENT RELATED TRAININGS / SEMINARS ATTENDED(Use additional sheet if

necessary. Please attach photocopy of certificate.)
Title of Training/ Condu No. of Hours
Venue Date/s Certificate No.
Seminar cted by

Department of Environment and Natural Resources

Environmental Management Bureau Region 2

EMB-R02-FM-CPD-PCO-019 00 08-14-19
 Pollution Control Officer Revision No. 1 ( )
(PCO) Accreditation Application Form Page 3 of 3 Remarks
(New/Renewal)
Letter of transmittal addressed to the Regional Director (to be
signed by Managing Director)
2. Duly Accomplished PCO Accreditation Application Form
downloadable at http://r2.emb.gov.ph

Letter of appointment/designation as PCO/Managing Head of the

establishment
Curriculum vitae with ID Picture of the appointed/designated
PCO

Certificate of Full Time employment appointed as PCO.

Copy of Diploma or TOR of the designated PCO.

6. Notarized Affidavit of Joint Undertaking of the PCO and the
Managing Head downloadable at http://r2.emb.gov.ph

Certificate of Training for forty (40) hours of Basic PCO Training

(Attended within the last 3 years)
For the Managing Head, Certificate of Training for eight (8) hours
on environmental management
For Category B Establishments, include copy of valid Professional
Regulation Commission License, if applicable.

Processing Fee of Php 500.00.

For the Owner of Establishment (Proof of Ownership i.e.: SEC /
DTI Certificate)
7. For Managing Head & PCO at the same time, Organizational
Chart

Do you have any pending

a) Administrative case Yes No b) Criminal Yes No

case

If you have any, give details of the case _________________________________________

_________________________________________
Name and Signature of Applicant / Date

Verified by:

_____________________________________________
Name and Signature of EMB Personnel / Date

EMB-R02-FM-CPD-PCO-019 00 08-14-19