Appendix REPUBLIC OF THE PHILIPPINES. DEPARTMENT OF ENERGY Renewable Energy Management Bureau Fort Bonifacio, Metro Manila APPLICATION FOR SAFETY ENGINEER'S / OFFICER’S PERMIT NAME SEX RESIDENCE, DATE OF BIRTH PLACE OF BIRTH: CITIZENSHIP CIVIL STATUS, EMPLOYER ADDRESS DESIGNATION: ACR No, EDUCATIONAL ATTAINMENT DATE ATTENDED DEGREE COMPLETED ELEMENTARY SECONDARY VOCATIONAL COLLEGE POST GRADUATE WORK EXPERIENCE NAME & ADDRESS OF EMPLOYER: __ INCLUSIVE DATE LAST POSITION HELD: ee ‘TRAININGSEMINARS: INCLUSIVE DATES: _ SKILLS/SPECIAL QUALIFICATIONS: GOVERNMENT EXAMINATION PASSED: Thereby certify thatthe statements given above are true and cozrect tothe best of my knowledge Signature of Applicant Date SUBSCRIBED AND SWORN to before me, affiant exhibit to me his/her Residence Certificate No. Issued at on ‘Notary Public ‘Do not fill beyond this point 3H Date Received Evaluate: Evaluated by: Result of Evaluation: Recommending Approval: ae Action Taken: Approved by