Form: SLA-09 Rm 213 (Compliance Service), PDEA Bldg., NIA Northside Road, Bgy. Pinyahan, Q.C.1100 Tel.

No: 927-9702 loc. 198, 197 / Telefax: 920-8110 Email: pdea_cs@yahoo.com.ph / Website: pdea.gov.ph APPLICATION SHEET (S-LICENSE) (Non Practitioners Registration - License to Handle Dangerous Drugs/ Dangerous Drug Preparation/s / Table I Controlled Chemical/s used in the manufacture of drug preparations &/or their Drug Preparation/s) DATE NEW RENEWAL MARK APPROPRIATE BOXES WITH
FILL OUT BLANKS. TYPE OR PRINT LEGIBLY. ONLY SIGNED FORMS WITH COMPLETE DOCUMENTS/ REQUIREMENTS WILL BE PROCESSED.
S- LICENSE APPLIED FOR NAME OF ESTABLISHMENT ESTABLISHMENT TYPE SECTOR BUSINESS ADDRESS WHSE ADDRESS E-MAIL ADDRESS TEL. NO. Office Warehouse NATURE OF BUSINESS ZIP CODE ZIP CODE FAX NO. Government Private

PHILIPPINE DRUG ENFORCEMENT AGENCY

S1

S3

S4

S5C

S5D

S5-E

S5-I

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Company Representative/s Information and Identification Numbers

NAME OF HEAD OF OFFICE DESIGNATION HOME ADDRESS E-MAIL ADDRESS TEL. NO. / MOBILE NO. NATIONALITY 1. TIN CARD / ITR 1a. TIN 1b. Date Issued (one-time submission) 2. NBI CLEARANCE 2a. Findings 2b. Date Issued (one-time submission) 3. LETTER OF AUTHORIZATION Dated (one-time submission) 4. NOTARIZED JOINT AFFIDAVIT Dated 1a. If foreign national, passport or ACR or AEP 1b 2a 2b 3 NAME OF AUTHORIZED PHARMACIST DESIGNATION HOME ADDRESS E-MAIL ADDRESS TEL. / MOBILE NO. NATIONALITY 5. TIN CARD / ITR 5a. TIN 5b. Date Issued (one-time submission) 6. NBI CLEARANCE 6a. Findings 6b. Date Issued 7. PRC ID CARD 7a. Registration No. 7b. Registration Date 7c. Valid until 8. PTR 8a. PTR No. 8b. Date Issued 15. PROJECTION FOR FORTHCOMING YEAR 16. CERTIFICATE OF PRODUCT REGISTRATION (CPR) 16a. Check if submitted 16b. Quantity of CPRs submitted 17a. PICTURE OF DDPs 17b. BOX LABEL 17c PACKAGEINSERT (one-time submission only) 18. COMPANY PROFILE 19. ORGANIZATIONAL STRUCTURE 20. LOCATION / VICINITY MAP 21. FLOOR PLAN/LAYOUT TO HIGHLIGHT STORAGE AREA 22. PICTURE OF DRUG ESTABLISHMENT (FRONTVIEW) 23. PICTURE OF CONTROLLED DRUG STORAGE AREA 24. PROOF OF OWNERSHIP / LEASE CONTRACT 25. LATEST SEMI-ANNUAL REPORT SUBMITTED 26. REGISTER WITH UPDATED RECORDING 27 LATEST S- LICENSE ISSUED ./ S LICENSE # 5a 5b 6a 6b 7a 7b 7c 8a 8b 15 For importers &/or manufacturers only Importer Manufacturer For importers / manufacturers / exporters only 16a 17a. For 17b. For importers / importers / manufacturers / manufacturers / exporters only exporters only 18. (one-time submission) 19. (one-time submission) 20. (one-time submission) 21. (one-time submission) 22. (one-time submission) 23. (one-time submission) 24. (one-time submission) 25 26 27 17c. For importers / manufacturers / exporters only 16b

Company Identification Numbers / Other Information

9. TIN CARD / ITR 9a. TIN 9b. Date Issued (one-time submission) 10. DTI / SEC / CDA CERTIFICATE ONLY 10a. Registration No. 10b. Validity 11. GIS (for corporations only) Dated 12. MAYORS PERMIT 12a. MP No. 12b. Date Issued 12c. Valid Until 9a 9b 10a 10b 11 12a 12b 12c 13. DOH BFAD LTO / CHD CERTIFICATE 13a. BFAD LTO No. / CHD No. 13b. Date Issued 13c. Valid Until 14. BOC ACCREDITATION CERTIFICATE (For importers only) 14a. BOC No. 14b. Date issued 13a 13b 13c 14a

14b

LIST OF CONTROLLED DRUGS HANDLED

I SOLEMNLY SWEAR that the statements made on this Application Form are true and the attached supporting documents are authentic. It is understood that the Company/Establishment and its responsible signatory officers are bound to comply with the provisions of R.A. 9165, otherwise known as the Comprehensive Dangerous Drugs Act of 2002 and other pertinent rules and regulations implemented by the Philippine Drug Enforcement Agency.

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Printed Name and Signature of Head of Office

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Printed Name, Signature of Authorized Pharmacist/Signatory