MGB Form No.

13-1

Republic of the Philippines

Department of Environment and Natural Resources
MINES AND GEOSCIENCES BUREAU
North Avenue, Diliman, Quezon City

APPLICATION FOR
ACCREDITATION AS DEALER, TRADER, OR RETAILER OF
MINERALS/MINERAL PRODUCTS AND/OR
BY-PRODUCTS

Application No. _____________________ Date Filed _________________________

Applicant ______________________________________________________________
(Business Name of Individual, Corporation, Partnership)

Name of Responsible Corporate Official, Proprietor, Owner, Attorney-In- Fact

_______________________________________________________________________

Date of Registration ______________________________________________________

(If Corporation or Partnership)

Business Address _________________________________________________________

Citizenship ______________________________________________________________

Mineral/s, Mineral Product/s and By-products

________________________________________________________________________

Name/s of Supplier/s Address Permit/Lessee/Contract No.

a. ______________________________________________________________________
b. ______________________________________________________________________
c. ______________________________________________________________________
d. ______________________________________________________________________
e. ______________________________________________________________________
(Use back page if space is not enough)

1. In accordance with the provisions of the DENR Administrative Order No. 96-40 or
the revised Implementing Rules and Regulations of RA No. 7942, the undersigned
citizen of the ________________________________________ for and in behalf of
_____________________________________________________ hereby
(Business Name)
applies for accreditation as a DEALER, TRADER and/or RETAILER of
minerals/mineral products/by-products enumerated or described above.

2. The applicant agrees that the statements made in the application or made later in
support hereof, shall be considered as conditions and essential parts of the
accreditations that may be granted by virtue thereof and any falsehood in these
statements or omissions of facts which may later change, or effect substantially the
facts set forth in said statements shall be sufficient ground for the nullification of the
accreditation granted.
MGB Form No. 13-1

3. The applicant further agrees to submit additional requirements should the DENR
SECRETARY, DIRECTOR or MINES REGIONAL DIRECTOR deem necessary for
purposes of determining his qualification for the accreditation applied for.

4. 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.

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

6. An application fee of P ______________ has been paid under Official Receipt No.
_________________ dated _______________, 199______.

________________________
Applicant
T.I.N. __________________

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 _______