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Department of Environment and Natural Resources

Environmental Management Bureau


National Capital Region Please attach your
2 x 2 picture
Pollution Control Officer (PCO) Accreditation Revision No. 1 here
Application Form (New) Page 1 of 3

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 Dates Degree/Units Earned

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