MGB Form No.

08-3B

Republic of the Philippines

PROVINCIAL/CITY MINING REGULATORY BOARD (P/CMRB)
Province/City of ________________

APPLICATION FOR
EXCLUSIVE SAND AND GRAVEL PERMIT/
GOVERNMENT/PRIVATE GRATUITOUS PERMIT
Application No. ____________________ Date Filed ________________________
Applicant ________________________________________________________
Address ________________________________________________________
Location/Area of Interest _______________________________________________

The Provincial Governor/City Mayor

Provincial/City Mining Regulatory Board
Province/City of ___________________

Sir :

In accordance with the provisions of the Philippine Mining Act of 1995 and the
Revised Implementing Rules and Regulations (IRR) promulgated thereunder, the
undersigned, _______________________________________, for and in behalf of
_____________________________________________, hereby applies for an Exclusive
Sand and Gravel Permit/Government/Private Gratuitous Permit to extract from a tract of
land containing sand and gravel materials and situated in Sitio _____________________,
Barangay _____________________, Municipality of _________________________,
Province of _________________________, Island of _________________________,
Philippines and bounded as follows:

On the North ____________________________________

On the East ____________________________________
On the South ____________________________________
On the West ____________________________________
with an approximate area of __________________________ hectares.

1. The area covered by this application is shown on the attached sketch/plan.

2. That the total amount of sand and gravel to be extracted during the whole period
of the Permit herein applied for will not exceed _______________ tons and the
permit for that amount only is hereby granted.
3. The applicant agrees that the statements made in this application or made later in
support hereof, shall be considered as conditions and essential parts of the
Exclusive Sand and Gravel Permit/Government/Private Gratuitous Permit that may
be granted by virtue thereof, and any falsehood in these statements or omission of
facts which may later change, or affect substantially the facts set forth in said
statements shall be sufficient cause for the cancellation of the permit granted.

4. This application is field 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 and the area is applied for the sole purpose of its development and
operation, and for speculation.

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MGB Form No. 08-3B

5. This application is for a period of sixty (60) days/coterminus with the construction
stage of the project but not to exceed one (1) year in public/private land/s.
6. The applicant agrees to pay the Government all the fees/taxes pursuant to the
provisions of RA No. 7729, amending Section 151 (a) of the National Internal
Revenue Code.
_______________________, Philippines ______________, 19____.

_________________________
Applicant
TIN _____________________

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 _______
INSTRUCTION
1. This application shall be accomplished in quintuplicate, two copies to be retained
by the applicant, the original and one copy to be forwarded to the Provincial/City
Mining Regulatory Board, and the remaining copy for the files of the MGB
Regional Office.
2. All pertinent information required shall be given, inapplicable word canceled, and
all blanks shall be filled up.
3. Application not accompanied with all the required documents shall not be
accepted.