MGB Form No.

08-3

Republic of the Philippines

PROVINCIAL/CITY MINING REGULATORY BOARD (P/CMRB)
Province/City of ________________

APPLICATION FOR QUARRY PERMIT

Application No. __________________________ Date Filed __________________

Applicant __________________________________________________________
Address __________________________________________________________
Size of Applied Area (hectares)_____________________________________________
Quarry Resources to be extracted/disposed __________________________________
Quantity ______________________________________________________________

The Provincial Governor/City Mayor

Provincial/City Mining Regulatory Board
Province/City of ___________________

Sir:

In accordance with the provisions of the Philippine Mining Act of 1995 and the
Revised Implementing Rules and Regulations promulgated thereunder, the undersigned
____________________________, for and in behalf of _______________________,
hereby applies for a permit to extract and dispose ___________________ materials from
a tract of land situated in Sitio _________________, Barangay ___________________,
Municipality of _______________________, Province of ___________________, Island
of _________________, and bounded by:

On the North: ______________________________

On the East: ______________________________

On the South: ______________________________

On the West: ______________________________

with an approximate area of __________________________ hectares.

1. The application fee of _________________________ has been paid under

Official Receipt No. ________________ dated ________________________,
Philippines.

2. The applicant agrees that the statements made in this application or made later in
support hereof, 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 later change, or affect substantially the facts set forth
in said statements shall be sufficient cause for the cancellation of the permit
granted.

3. This 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 applied for the sole purpose of its development and
operation, and for speculation.

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MGB Form No. 08-3

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

I, __________________________, the person executing this affidavit for this

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

___________________________
Applicant
TIN _______________________

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, the original and one copy to be forwarded to the Provincial/City
Mining Regulatory Board, and the remaining copy for the files of the MGB
Regional Office.

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

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