Republic of the Philippines

Department of Environment and Natural Resources

MINES AND GEOSCIENCES BUREAU
Region XI, Davao City

APPLICATION FOR: SAFETY:

(Permanent / Temporary) (Engineer / Inspector)

The REGIONAL DIRECTOR

Davao City

Sir:

I have the honor to apply, pursuant to the provisions of Department Administrative Order
No. 2000-98, otherwise known as the Mine Safety and Health Standards, for a permit to
act as: ____________________________ Safety: ________________________ and
(Permanent / Temporary) (Engineer / Inspector)
Hereby state, under oath, the following:

1. Name of Applicant:
2. Office Address:
3. Age: 4. Civil Status:
5. Place of Birth: 6. Date of Birth:
7. Citizenship: 8. How Acquired:

9. Name of Company:
10. Address:
11. Nature of Employment:
12. Position:

13. Educational Attainment:

Highest Degree
Name of School Location Date of Attendance Completed

(Attached herewith is a certified copy of my diploma or certificate of the school or university I last
attended)
14. Board Examination Taken:

Title of Examination Registration

Date Taken Rating Kind Number Date

(Attached herewith is a certified copy of the registration certificate given to me by the Board of
Examiners, Civil Service Commission)

15. Experience and Training

Name of Employer/s Address Date Employed Nature of Work

From To

(Attached herewith are the certificates of efficiency given to me by the Superintendent of Mining
Engineer under whom I work)

16. I oblige myself to present such documents or papers as maybe required or me by

the authorities concerned in connection with this application and submit myself to
such examination, oral and/or written, as may be deemed necessary to determine
my application.

17. I bind myself to observe and comply with all the laws, rules and regulations, orders
and instruction issued or to be issued by the duly constituted authorities relating to
the duties of a ___________________________ Safety _____________________
(Permanent / Temporary) (Engineer / Inspector)
and to the sanitation in the mine, mill or quarry.

18. I perfectly understand that the Temporary Permit if granted, is valid for three (3)
years not applicable to permanent registration, and only while in the employ of the
present employer; renewable every three (3) years while employed; that said
permit will be surrendered to the Director of Mines and Geosciences Bureau,
should I transfer employment.
19. I hereby certify that all the facts and statements made in this connection are all true
and correct.

Very respectfully yours,

___________________________________
(Signature over Printed Name of Applicant)

SUBSCRIBED AND SWORN TO before me at _______________________ this

_________ day of _____________________________, Affiant exhibited to me his
Residence Certificate No. ____________________ issued at _____________________
on ________________________.

_________________________
Notary Public
Doc. No. ____________
Page No. ____________
Book No. ____________
Series of ____________