REPUBLIC OF THE PHILIPPINES

PROVINCE OF BULACAN
CITY OF SAN JOSE DEL MONTE
BUSINESS PERMITS & LICENSING OFFICE
OFFICE OF THE CITY MAYOR
Application Form for Occupational Permit
for year 20_____
Date: _________________

Last Name : First Name: Middle Name:

Name of Applicant

Citizenship Sex Civil Status Contact No.

Birthplace Birthdate Height

Current Address

Highest Educational
Religion
Attainment

School Tin # SSS #

Position Title / Work

Email Address
Position

Company Name

Company Address
(Place of Work)

CTC # (Cedula) CTC Date CTC Amount

CTC Place of issue

Instructions:

1. Provide accurate information and print legibly to avoid delays. Incomplete application form will be returned to the applicant.
2. Ensure that all documents attached to this application form are complete and properly filled out.

Requirements:
1. Brgy. Clearance 5. Birth Certificate (for minor, GRO, and 18 years old)
2. Police Clearance or NBI Clearance 6. Notarized Affidavit of Parent`s Consent (for minor)
3. Cedula 7. Official Receipt
4. Health Card

I have read this form, understood its contents and hereby affix my signature to the processing of my personal data. I understood that my
consent does not preclude the existence of other criteria for lawful processing of personal data and does not waive any of my rights under the
Data Privacy Act of 2012 and other applicable laws.

___________________________________________
Applicant's Signature over Printed Name

Documents checked/verified by: (to be filled-out by the BPLO Personnel)

__________________________________________

BPLO-F-003 (Revision 0; November 15, 2018)