Republic of the Philippines PROVINCIAL GOVERNMENT OF CAVITE PHOTO. PROVINCIAL NUMBER CODING SCHEME EXEMPT STICKER = APPLICATION FORM Cher documents may be requied ature of exemoton Last Name Fest Noma Mido Name Sutera Ext. (any) Tareas No, Sirt Subdsion sage Cityntunespaty Date of Birth (mmadyyyy): Gender: [Male CFemaie ‘Contact No: Email Address: | Company Name: ‘Company Address: Plate No. / Conduction Star No Wake. Toyota) ‘Serie: (0.9, Vos TE) Year Wade ORNS: CR No | Aeplicant’s Underiaking — | hereby bind myself o foto the rules and regulations set by the Provincial Government of Cavite (PGC) governing the use of Provincial Number Coding Scheme Exempt (PNCSE) Stickers. | ceclae that | am fuy aware that each PNCSE Sticker with a spectic Contr! Numbers non-transferable and is strictly exclusive for one vehicle registered under one person/company only. | shall not copy, distbue, reproduce in any manner, offer forsale or re-aal, and transfer in ‘whole on part the sticker issued to me by PGC. Any falure to comply with the foregoing oF any deed in abuse of authorty or exemption granted under Provincial Orinance No. 164 known as “The Number Coding Scheme Ordinance of the Province of Cavite" and its implementing Rules and ‘Regulations shall be meted wi penalty of Five Thousand Pesos (P5,000.00) andlor imprisonment of one (1) year. at the discretion ofthe court, thou prejudice to the fing ofthe appropriate administrative action against the ering pubic oficar " cetity that Ihave read and understoed all information herein sated and further catty that al information provided inthis application are true and correct. “Forms without approval rom the wil not be accepted ar fe Official Receipt No. Payment Accepted by: Load ‘Amount: & Prete Noe on Sata) ies PNCSE Sticker Control No. PNCSE Sticker Released and Affixed by: Date {Preted Name snd Signet) ee PNCSE Sticker Received by: Dae | Remarks: [Time —| (Prntes name ana Spratr) 'PHCSE Form No.1 (January 2018). This Form i NOT for sal. Reproduction is alowed,