Republic of the Philippines

Department of Environment and Natural Resources

MINES AND GEOSCIENCES BUREAU
North Avenue, Diliman, Quezon City

APPLICATION FOR PERMANENT / TEMPORARY SAFETY

ENGINEER / INSPECTOR

(Date)
The Regional Director
Mines and Geosciences Bureau
Regional Office No. 10
Cagayan de Oro City
Sir:
Pursuant to the provisions of Republic Act No. 7942, the Revised Implementing Rules and
Regulations and Department Administrative Order No. 2010-21, I
Menilo B. Decir Jr
have the honor to apply for a Permit to act as
Temporary
Safety
Insoector
under oath, the following:
(Permanent/Temporary)
(Inspector/Engineer)
1.
2.
3.
4.
5.
6.

Name of Applicant
Post Office Address
Contact No.
Age
Date of Birth
Citizenship

:
:
:
:
:
:

Menilo B. Decir Jr
Poblacion Manticao Misamis Oriental
09164000293
25
Civil Status : Single
08/21/1990
Place of Birth : Iligan City
Filipino
How Acquired : By birth
(by birth, naturalization, etc.)

If Alien:
Last residence before coming to the Philippines
Date of arrival in the Philippines
Landing Certificate No.
Did you come on contract of employment?
If so, state nature of employment and
Name of Company

:
:
:
:
:
:

n/a
n/a
n/a
n/a
n/a
n/a

7.

Present Employment :
Name of Company : BNM3 Enterprises and General Services
Address of Company : Tubod Noville Iligan City

8.

Educational Attainment: (Use additional sheet if necessary)

Name of School
Mindao Mission Academy

MSU- NILSHS
Liceo de Cagayan University

MSH College

Address/Location
Pob. Manticao Mis. Or.
Pob. Naawan Mis. Or.
Carmen, Cagayan de Oro
San Miguel, Iligan City

Date of
Attendance
2002-2003
2006-2007
2007-2009
20011-2012

Units Earned or
Degree Obtained
Elementary
High School
AHSE
BS- Nursing

9.

Board Examination Taken: (Use additional sheet if necessary)

Title of Examination

Date Taken

Rating

Kind

Registration
No.

Date

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

10
.

Work Experience: (Use additional sheet if necessary)

Position
(from recent to present)
Safety Officer

Inclusive Date
From
To
July 2013

Length of
Service
2 years

Status of
Company
Appointment
Present
BNM3

(Please attach original certificate of employment and job description duly certified by the Personnel Manager/
employer/or authorized company official
using official company letter head; and proof of practice
(safety report/programs prepared/implemented)

OSH Related Trainings / Seminars attended: (Use additional sheet if necessary)

Time / Duration
No. of
Conducted
Title
From
To
Hours
by
BOSH
07/15/13
40
OSHC
12/12/13 12/16/13
COSH
40
MSRS
03/12/14 03/14/14
PCO
24
GEAI
BIFSO
07/27/13 7/27/13
8
SOPI
BLS-CPR
04/5/14 04/7/14
24
PRC

Venue
Lugait FH
VIP Hotel
Luagit FH
PRC FH

(Please attach photocopy of certificates. Original copies of certificates to be presented to authorized MGB staff for
Certification).

11. I obligate myself to present such documents or papers as may be required of 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.

12
.

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

13
.

I perfectly understand that the Temporary Permit, if granted, is valid for one (1) year and three (3) years for
Permanent Permit and only while in the employ of the present employer; that said Permit will be surrendered
to the Director of Mines and Geosciences, should I transfer employment.

14
.

I hereby certify that all the facts and statements made in this connection are all true and correct.

Very respectfully yours,

Menilo B. Decir Jr

(signature of applicant)
(Below is for Notary Public use)
ACKNOWLEDGEMENT
SUBSCRIBED AND SWORN to before me this _________ day of ____________, 20____ affiant
exhibited to me his/her Community Tax Certificate No. ________________ issued on
__________________ at __________________________, Philippines.

NOTARY PUBLIC
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