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
