Republic of the Philippines

MUNICIPALITY OF BAGANGA
Baganga, Davao Oriental

APPLICATION FOR LOCATIONAL CLEARANCE

Application No. : _________________________ Date Issued : _________________________
Date of Receipt : _________________________ Amount Paid : Php _____________________
PMO No./OR No. : _________________________

1. NAME OF APPLICANT (Last, First, Middle) 2. NAME OF CORPORATION

3. ADDRESS OF APPLICANT 4. ADDRESS OF CORPORATION

5. NAME OF AUTHORIZED REPRESENTATIVE 6. ADDRESS/TEL.OF AUTHORIZED REPRESENTATIVE

7. PROJECT TYPE 8. PROJECT NATURE

( ) New Development () Others (specify)
_______________________
9.PROJECT LOCATION 10. PROJECT AREA (in square meters)
(No. Street, Bgry., Municipality/Province) Lot : __________
Bldg. : __________ Improvement __________________
11. RIGHT OVER LAND 12. PROJECT NATURE
( ) Owner Others (Specify) ( ) Permanent
( ) Lease ______________________ ( ) Temporary
13. EXISTING LAND USE OF PROJECT SITE
( ) Residential ( ) Commercial ( ) Others ( ) Vacant/Idle ( ) Agricultural (Specify Crop) _______________
( ) Institutional ( ) Industrial ( ) Tenanted ( ) Not tenanted
14. PROJECT COST (in pesos, write in words and figures)
______________________________________________________________ (Php ________________________)
15. IS THE PROJECT APPLIED FOR THE SUBJECT OF WRITTEN NOTICE (S) FROM THE LOCAL GOVERNMENT
UNIT (LGU) TO PRESENT OR APPLY FOR LOCATIONAL CLEARANCE (LC)?

( ) Yes (Pls. Indicate the following ( ) No

Issuing Officer
____________________________
Order in the Notice
____________________________
Date of Notice
____________________________
16. IS THE PROJECT APPLIED FOR THE SUBJECT OR RELATED ACTION(S) WITH OTHER OFFICES OF THE
BOARD AND/OR LOCAL GOVERNMENT UNIT?
( ) Yes (Please indicate the following) ( ) No
Office where similar action(s) was filed___________________
Date Filed ___________________________
Actions Taken ________________________
17.PREFERRED MODE OF RELEASE OF DECISION:
( ) Pick up ( ) By mail, addressed to ( ) Applicant ( ) Authorized Representative
18. SIGNATURE OF APPLICANT 19. SIGNATURE OF AUTHORIZED REPRESENTATIVE

Republic of the Philippines )

_____________________ ) S.S.

SUBSCRIBED AND SWORN TO before me this ______ day of ____________, 20___ in the City/ Municipality
of _______________, Province of_______________________. Affiant exhibited his./her Community Tax Certificate
No. ______________ at _________________ on ______________________.

NOTARY PUBLIC

Doc. No. _____________

Page No. _____________
Book No. _____________
Series No. _____________