Republic of the Philippines

DEPARTMENT OF ENERGY
Rizal Drive, Bonifacio Global City, Taguig City

APPLICATION FOR STANDARDS COMPLIANCE CERTIFICATE (SCC)

Household Liquefied Petroleum Gas (LPG)
Business Name

__________________________________________________

Address

__________________________________________________
__________________________________________________

Telephone No.

__________________________________________________

Fax No.

__________________________________________________

E-mail Address

__________________________________________________

Type of Ownership

:
Single Proprietorship

LPG activity category

Name of Owner (s),
Partner(s) or
Authorized Representative
(in case of Corporation)
Address

Refiller/Marketer

Marketer

Partnership

Hauler

Corporation

Dealer

Retailer

__________________________________________________

__________________________________________________
__________________________________________________

Telephone No.

__________________________________________________

Fax No.

__________________________________________________

E-mail Address

__________________________________________________

___________________________
Name and Signature of Applicant

Before
me,
the
undersigned
authority,
on
this
day
personally
appeared
______________________{name}, of ________________________{name of entity}, known to me to be
the person whose name is subscribed to the foregoing instrument, and upon his/her oath acknowledged to
me that he/she executed the same for the purposes and consideration therein expressed and in the
capacity therein stated.
GIVEN UNDER MY HAND AND SEAL OF OFFICE THIS _______ DAY OF ____________, 20__.

NOTARY PUBLIC
Doc. No.
Page No.
Book No.
Series of __________