I DECLARE UNDER PENALTY OF PERJURY that all information in this appication are true and correct based
on my personal knowledge and authentic records submmitted to the Local Government. Any false or misleading
information supplied, or production of documents shall be a ground for appropriated leagal action against me. I
also agree to comply with the post-regulatory requirements and other deficiencies (for renewal) within 30 days
from release of the permit. Further, I hereby authorize and consent the Local Government to treat any personal
data provided in this application with utmost confidentiality.