Kind of application (pls.

indicate if new or renewal)

BRANCH DETAILS
Branch code
Branch Name (copy from the latest s3 license)
Branch Address (copy from the latest S3 license)
ZIP code
Branch email address
Telephone number

Branch TIN number

Branch TIN date issued

Mayor's permit number

Mayor's permit Official Receipt number
Mayor's permit date issued

Lto number
LTO Official Receipt number
LTO date issued
LTO validity

S3 license number
S3 license validity
Latest SAR (covered period)
Exact Date Latest SAR was received by PDEA
(yung tinatakan ng received by)

DS DETAILS (pls indicate if same DS or change DS)

first name
middle initial
last name
Address
Gender
Nationality
Civil Status
Email Address
Contact number

TIN number (for change DS only)

TIN date issued (for change DS only)
NBI date issued (for change Ds only)
NBI expiration date (for change DS only)
Cedula number
Cedula date issued
Cedula place issued

PHARMACIST'S DETAILS (pls indicate if same PH or change PH)

CE NUMBER (FOR RFP PURPOSES)
first name
middle initial
last name
Address
Gender
Nationality
Civil Status
Email Address
Contact number

TIN number (for change ph only)

TIN date issued (for change ph only)
NBI date issued
NBI expiration date
Cedula number
Cedula date issued
Cedula place issued
PRC Registration number
PRC Registration Date
PRC ID validity
PTR number
PTR date issued

DOCS AVAILABILITY available or not available?

SEC
GIS 2016
VICINITY MAP
FLOOR PLAN
CONTRACT OF LEASE (valid)

DD CABINET STATUS
with single lock or double lock?
movable or fixed (attached to wall or floor)
visible to customers or not?