F No.

SD-SCD-QF15
O Revision No. 3
R Effectivity Date: 01 May 2016
M Page 1 of 1

BPS PRODUCT CERTIFICATION SCHEME

Application for Extension / Reduction in the Scope of

CERTIFIED PS CERTIFICATION CERTIFIED
Product Quality Product Safety

Date: ________________
The Bureau Director
Bureau of Philippine Standards
Department of Trade and Industry
3/F, Trade and Industry Building
361 Sen. Gil J. Puyat Avenue
Makati City

Sir:
In accordance with Department Administrative Order No.4:2008 and its future amendments, promulgated pursuant to Section 79 (B) of
the Revised Administrative Code of the Philippines and Executive Order No. 101, Series of 1967, in conjunction with the provisions of R.A. 4109
and R.A. 7394, we hereby apply for extension/reduction in the scope of the Philippine Standard (PS) Quality and/or Safety Certification Mark.
CHANGES/
COMPANYPROFILE UPDATE
YES NO
Company’s Registered Name
Complete Plant Address
PS License Number
Telephonenumbers
Facsimile numbers
Email address
President/ General Manager
Quality Management Representative
Deputy Quality Management Rep.
Product
Product Standard
Specific model/type/sizes applied for :
 Extension
 Reduction
(For DTI use only)

In the event the application is granted, we hereby agree to abide by all terms
EVALUATION AND RECOMMENDATION
and conditions thereof and all other rules and regulations, including amendments
thereto, prescribed for its use.
 for INCLUSION to PS License subject to satisfactory
IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of
result of:
_______20__ at______________, Makati, Philippines.
 QMS Audit
 Product Audit
________________________  Sampling
Print Name and Signature  Independent test
(President/General Manager)  Verification

SUBSCRIBED AND SWORN
_________________20__, Affiant exhibited to me his/her residence certificate no.
____________________ issued
______________________.
Doc. No. __________
Page No. __________
Book No. __________
Series of __________
to before me this _____day of  for REDUCTION from PS License
at _________________ on  Others _____________________
Remarks: ____________________________________
____________________________________
NOTARY PUBLIC
Evaluated and Recommended by:
______________________
Product Certification Officer

Note: If the PS applicant is foreign, this application shall be authenticated by the Philippine Embassy that covers the plant location.