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MGB Form No.

25-1

Republic of the Philippines


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

APPLICATION FOR ORDER OF SURVEY OF MINERAL RIGHTS


(MINERAL AGREEMENT/FINANCIAL AND TECHNICAL
ASSISTANCE AGREEMENT)

____________________
(Date)
The Director
MGB Regional Office No. ____
__________________________
__________________________

Sir:

I have the honor to request that pursuant to the Philippine Mining Act of 1995 and
the revised Implementing Rules and Regulations promulgated thereunder, an order for
mineral rights survey be issued by your Office to Geodetic Engineer
_______________________ with G.E. No. ___________ P.T.R.No. ________________
and postal address at _____________________________________________________.
The areas covered by this application are contained in the attached Sketch Plan and
application/s for guidance of the geodetic engineer in the execution of the survey of the
following mineral rights:

MINERAL RIGHT/S APPLICANT/ DATE LOCATION


CONTRACTOR FILED (Sitio, Bgy., Mun. Prov.)

In this connection, it is understood that the mineral rights survey applied for covering the
mining rights application/s above-mentioned will not necessarily give me any preferential
and/or additional rights, that no extension for the submittal of survey returns shall be
allowed unless for reasons of force majeure and that the said survey shall be subject to
the final outcome of any case involving the said mining right/s application/s.

Very truly yours,

_____________________
Applicant
T.I.N.______________

I HEREBY ACCEPT THIS ASSIGNMENT:

_____________________
Deputy Geodetic Engineer
T.I.N. ____________

Processing fee paid under O. R. No. _____________ dated ____________ 19 __ in the


amount of P .

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