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    5.PCO Accreditation Application Form (1)

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    starglazehandicraftexport

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    © All Rights Reserved
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    5.PCO Accreditation Application Form (1)

    Uploaded by

    starglazehandicraftexport
    1 views3 pages

    Copyright

    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1 views3 pages

    5.PCO Accreditation Application Form (1)

    Uploaded by

    starglazehandicraftexport

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    You are on page 1of 3

    Department of Environment and Natural Resources

    Environmental Management Bureau


    Please indicate your Region Please attach
    your
    2” x 2” picture
    Pollution Control Officer (PCO) Revision No. 1 here
    Accreditation Page 1 of 3
    Application Form (New)
    Instructions:
    Fill in all the data needed. If the blanks are not applicable, write N.A.
    PROFILE
    Last Name First Name Middle Name Sex: Citizenship:
    Male
    Female
    Home Address (Number & Street, Town/City, Employment Current Position:
    Province, Zip Code) Status:
    Full-time No. of Years in
    Current Position:
    Part-time
    Effectivity of Appointment
    Others as PCO:

    Telephone No.: Cellular Phone No.: E-mail Address:

    ACCREDITATION INFORMATION
    Project Name / Establishment Name: Name of Managing Head:

    Position:

    Project Location Address (Number & Street, Nature of Business Establishment Category
    Town/City, Province, Zip Code) of the based on DAO 2014-02:
    Establishment:

    Telephone No.: Fax No.: Website:

    ✓ QUANTITY & CLASSIFICATION:


    Handling / Storing Chemicals
    Listed in Annex 1 of DAO 2014-02
    Hazardous Waste Generated:

    With Centralized MRF / Sanitary


    Landfill:
    Generator Set / Boiler Capacity
    (Kw / KvA / Hp):
    Waste water discharged (cu.m/day):

    Transporter / Treater of Sludge:

    Other Sources of pollution:


    Department of Environment and Natural Resources
    Environmental Management Bureau
    National Capital Region
    Pollution Control Officer (PCO) Accreditation Revision No. 1
    Application Form (New) Page 2 of 3
    HIGHEST EDUCATIONAL ATTAINMENT
    School Address Inclusive Degree/Units Earned
    Dates

    Type of PRC License received (if any):

    PRC License No.: Date Issued: Validity:

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


    Certificate of Employment)
    Status of Employment
    Company Position Inclusive Dates

    ENVIRONMENT RELATED TRAININGS / SEMINARS ATTENDED(Use additional sheet if


    necessary. Please attach photocopy of certificate.)
    Title of Training/ Conducted No. of
    Venue Date/s Certificate No.
    Seminar by Hours
    Department of Environment and Natural Resources
    Environmental Management Bureau
    National Capital Region
    Pollution Control Officer (PCO) Accreditation Revision No. 1
    Application Form (New) Page 3 of 3
    OTHER REQUIREMENTS (Please attach the following requirements)
    Letter of appointment/designation as PCO/Managing Head of the establishment

    Curriculum vitae with ID Picture of the appointed/designated PCO

    Certificate of Full Time employment appointed as PCO.

    Copy of Diploma or TOR of the 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 (Attended within
    the last 3 years)
    For the Managing Head, Certificate of Training for eight (8) hours on environmental
    management
    For Category B Establishments, include copy of valid Professional Regulation
    Commission License, if applicable.
    Processing Fee of Php 500.00.

    Do you have any pending

    a) Administrative case Yes No b) Criminal case Yes No

    If you have any, give details of the case _________________________________________

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

    _________________________________________
    Name and Signature of Applicant / Date

    Verified by:

    _____________________________________________
    Name and Signature of EMB Personnel / Date

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