REVISED PNP FORM 6-A1

As of April 2016
Republic of the Philippines
NATIONAL POLICE COMMISSION
PHILIPPINE NATIONAL POLICE
Camp Crame, Quezon City PASSPORT SIZE OF THE
APPLICANT/APPLICANT-
REPRESENTATIVE

APPLICATION FOR LICENSE

CHIEF, PHILIPPINES NATIONAL POLICE
Camp Crame, Quezon City

Type of Application New Renewal Amendment Date of Application

Company Name CLEAN LEAF INTERNATIONAL CORPORATION

Nature / Line of Sector

Business Manufacturer Dealer Purchaser Government Private School

Office Address ZIP Code

397 M.H. DEL PILAR ST., MAYSILO, MALABON CITY 1477
Facility Address ZIP Code
397 M.H. DEL PILAR ST., MAYSILO, MALABON CITY 1477
Warehouse Address

COMPANY HEAD AND/OR AUTHORIZED REPRESENTATIVE/S INFORMATION

Name of Company Designation
ATTY. EMILY G. CLAVERIA PRESIDENT
Head
Home Address ZIP Code
# 33 SAINT DOMINIC DRIVE, BAESA, QUEZON CITY 1106
Contact #s Email Address
02 961 6405 info@cleanleaf.com.ph
Name of Authorized Designation
CHRISTIAN CASTILLO
Representative
Home Address ZIP Code
397 M.H. DEL PILAR ST., MAYSILO, MALABON CITY 1477
Contact #s Email Address
02 961 6405

CONTROLLED CHEMICAL/S TO BE LICENSED:

QTY RECOMMENDED
KIND QUANTITY APPLIED REMARKS
BY FEO
SULFURIC ACID Indicate storage capacity
HYDROCHLORIC ACID versus production capacity
TOLUENE for one (1) year

In support of this application, the undersigned applicant/applicant-representative enclosed hereto the original/authenticated copies of the following documentary
requirements:
For applicant: shall be represented by the owner, in case of sole proprietorships or partnerships, or, in case of corporations, by the president or
any corporate officer or member of the Board empowered through a Secretarys Certificate.
For authorized representative: Special Power of Attorney (SPA) stating that he/she has been authorized by the applicant for the purpose of
processing the application for license.
For local corporation/partnership: Certificate of Registration of the firm with the Securities and Exchange Commission (SEC) to include its
machine validated Articles of Incorporation and General Information Sheet (GIS). (For New and Amendment)
For foreign multi-corporation: SEC Registration to do business to do business in the Philippines.
For Single Proprietorship: Certificate of Registration with the Department of Trade and Industry (DTI). (For New and Amendment)

Personal Data Sheet (PDS) of the applicant and the management personnel of the storage facility/warehouse. (For New and Amendment)
NBI Clearance of the applicant (For New and Amendment)

Business Permit
Process flowchart. (For New and Amendment)

Material Safety Data Sheet (MSDS)/Safety Data Sheet (SDS) of controlled chemicals. (For New and Amendment)
Vicinity Map of the factory and storage facility showing distance from the nearest Police Headquarters

Floor/Location Plan of the storage facility (For New and Amendment)

For Metro Manila Applicant: Security Survey Inspection from Chief of Police and Certificate of Inspection from C, EEMD, FEO.

For outside Metro Manila Applicant: Security Survey Inspection from Provincial Director/City Director
Proof of Payment from the Land Bank of the Philippines

Certificate of Good Standing (as applicable)

I solemnly swear that the information above are true and correct. Further, in compliance with the requirements pertaining to controlled chemicals which are now or
hereafter maybe enforced and in adherence to existing laws, rules and regulations, I would like to request your good office to conduct security survey and storage facility
inspection in connection with our application as indicated above.

ATTY. EMILY G. CLAVERIA

Printed Name and Signature of Applicant
 DO NOT WRITE BELOW THIS LINE. FOR PNP USE ONLY.

The undersigned respectfully RECOMMENDS THE APPROVAL of the application and certifies the completeness and
validity of applicants documentary requirements.
Attached is the Security Survey Inspection Report
The undersigned regretfully DENY THE APPLICATION due to the following:
Incomplete documentary requirements, i.e ; and

Area is not safe pursuant to the Security Survey Inspection Report.

PROVINCIAL DIRECTOR/CITY DIRECTOR

The undersigned respectfully RECOMMENDS THE APPROVAL of the application and certifies the completeness of
applicants documentary requirements. The undersigned further recommends the following:
Quantity of the controlled chemicals pursuant to the Storage Inspection Report; and

Attached are the following documents:

Properly labeled pictures (8x10 in size) of storage facility with PNP Inspecting Team printed in photo paper; and
Storage Facility Inspection Report.
The undersigned regretfully DENY THE APPLICATION due to the following:
Incomplete documentary requirements, i.e ;
Area is not safe pursuant to the Security Survey Inspection Report; and
Storage Facility does not conform to the parameters pursuant to the Storage Facility Inspection Report.

CHIEF, REGIONAL CIVIL SECURITY UNIT

The undersigned respectfully RECOMMENDS THE APPROVAL of the application and certifies the completeness of
applicants documentary requirements
Attached are the following documents:
Properly labeled pictures (8x10 in size) of storage facility with PNP Inspecting Team printed in photo paper.
Storage Facility Inspection Report.
The undersigned regretfully DENY THE APPLICATION due to the following:
Incomplete documentary requirements, i.e. ;
Area is not safe pursuant to the Security Survey Inspection Report; and
Storage Facility does not conform to the parameters pursuant to the Storage Facility Inspection Report.

CHIEF, EXPLOSIVES MANAGEMENT DIVISION

RECOMMEND:
APPROVAL
DISAPPROVAL

CHIEF, FIREARMS AND EXPLOSIVES OFFICE

RECOMMEND:
APPROVAL
DISAPPROVAL

DIRECTOR, CIVIL SECURITY GROUP

APPROVED: This license shall be valid for a period of year/s from the date of issuance subject to the conditions
and guidelines imposed under RA No. 9516 and its Implementing Rules and Regulations, other laws, rules and
regulations.
DISAPPROVED

CHIEF, PHILIPPINE NATIONAL POLICE