Department of Environment and Natural Resources

Environmental Management BureauPlease attach your 1 x 1 picture here

Pollution Control Officer (PCO) Accreditation

Application Form (New)Revision No. 0

Page 1 of 3

Instructions:

Fill in all the data needed. If the blanks are not applicable, write N.A.

PROFILE

Last Name

LEGADAFirst Name

JERALDENMiddle Name

DIATRASSex:Citizenship:

FILIPINO

Male

*Female

Home Address (Number & Street, Town/City, Province, Zip Code)

General Santos City

Employment Status:Current Position:CRO

*Full-timeNo. of Years in Current Position:1 yr

Part-time

Others

Telephone No.:

083-552-4781Cellular Phone No.:

0921-366-0875E-mail Address:

micei.customerrelations @gmail.com

Name of Establishment:

Mindanao Integrated Commercial Entrp.,Inc

Name of Managing Head:

Nereo G. Regollo

Employment Address (Number & Street, Town/City, Province, Zip Code)

Natl Highway General Santos City

Nature of Business of the Establishment:Car DealerEstablishment Category based on DAO 20AA-BB:

Telephone No.:

083-552-4781Fax No.:302-0586Website:

EDUCATIONAL ATTAINMENT

SchoolAddressInclusive DatesDegree/Units Earned

NDTCTacurong City2004-2008BSBA

Type of Professional License received (if any):

PRC License No.:

Date Issued:Validity:

Department of Environment and Natural Resources

Environmental Management Bureau

Pollution Control Officer (PCO) Accreditation

Application Form (New)Revision No. 0

Page 2 of 3

WORK EXPERIENCE (Use additional sheet if necessary. Please attach photocopy of Certificate of Employment)

CompanyPositionInclusive DatesStatus of Employment

Best MobileOffice staffMarch December 2011

Regular

TRAININGS/SEMINARS ATTENDED (Use additional sheet if necessary. Please attach photocopy of certificate.)

Title of Training/ SeminarVenueConducted byDate/sNo. of HoursCertificate No.

Department of Environment and Natural Resources

Environmental Management Bureau

Pollution Control Officer (PCO) Accreditation

Application Form (New)Revision No. 0

Page 3 of 3

OTHER REQUIREMENTS (Please attach the following requirements)

Letter of appointment/designation as PCO of the establishment

Curriculum vitae with ID Picture of the appointed/designated PCO

Notarized Affidavit of Joint Undertaking of the PCO and the Managing Head

Certificate of Training for forty (40) hours of Basic PCO Training

For the Managing Head, Certificate of Training for eight (8) hours on environmental management

Do you have any pending

a) Administrative caseYes*Nob) Criminal caseYes*No

If you have any, give details of the case _________________________________________

I certify that all the information stated above are true and correct.

JERALDEN D. LEGADA

_________________________________________Name and Signature of Applicant / Date

Verified by:

_____________________________________________

Name and Signature of EMB Personnel / Date