FM-CSVlrd-02

PHILIPPINE DRUG ENFORCEMENT AGENCY

Compliance Service Room 213, PDEA Bldg., NIA Northside Road, Bgy. Pinyahan, Q.C.1100
Tel. No: 927-9702 loc. 197, 198 / Telefax: 920-8110
Email: cs@pdea.gov.ph / Website: pdea.gov.ph

S-LICENSE APPLICATION FORM FOR NON-PRACTITIONER’S

(Handling Dangerous Drugs/ Dangerous Drug Preparation/s /Table I Controlled Chemical/s used in the manufacture of drug preparation)
DATE:
MARK APPROPRIATELY BOXES WITH √  NEW  RENEWAL
FILL-OUT BLANKS. TYPE OR PRINT LEGIBLY. ONLY SIGNED FORMS WITH COMPLETE DOCUMENTS/ REQUIREMENTS WILL BE PROCESSED.
FOR NEW APPLICANTS: ONLY THE HEAD OR AUTHORIZED PHARMACIST/SIGNATORY SHALL BE ALLOWED TO TRANSACT BUSINESS WITH PDEA.
PRESENT ORIGINAL DOCUMENTS FOR VALIDATION AND SUBMIT CLEAR PHOTOCOPY
S- LICENSE APPLIED FOR S1 S3 S4 S5C S5D S5-E S5-I S6
NAME OF
ESTABLISHMENT
ESTABLISHMENT TYPE  Office Warehouse

NATURE OF
SECTOR Private
Government  BUSINESS
OFFICE / BUSINESS
ZIP CODE
ADDRESS

WHSE / PLANT ADDRESS ZIP CODE

E-MAIL ADDRESS TEL. NO. FAX NO.

ENTITY’S REPRESENTATIVE INFORMATION

NAME OF HEAD OF NAME OF AUTHORIZED
OFFICE PHARMACIST
DESIGNATION DESIGNATION

HOME ADDRESS HOME ADDRESS

E-MAIL ADDRESS E-MAIL ADDRESS
TEL. NO. / MOBILE NO. TEL. / MOBILE NO.
NATIONALITY NATIONALITY
1. TIN CARD / ITR 1a. If foreign national, passport or ACR or AEP 5. TIN CARD / ITR / BIR TIN 5a
1a. TIN No. VERIFICATION SLIP / e - TIN
1b. Date Issued 1b 5a. TIN No. 5b
(one-time submission) 5b. Date Issued (one-time submission)
2. NBI CLEARANCE 2a 6. NBI CLEARANCE 6a
2a. Clearance with Findings 6a. Clearance with Findings
2b. Date Issued 2b 6b. Date Issued 6b
(one-time submission)
3. LETTER OF 3 7. PRC ID CARD 7a
AUTHORIZATION ISSUED 7a. Registration No.
7b
ON (original) 7b. Registration Date
(one-time submission) 7c. Valid until 7c
4. NOTARIZED JOINT 4 8. PTR / COE for government 8a
AFFIDAVIT SWORNED ON 8a. PTR No. (original- copy)
(original) 8b. Date Issued 8b

ENTITY’S INFORMATION
9. TIN CARD / ITR 9a 15. FORECAST FOR 15 For importers &/or manufacturers only
9a. TIN NO. FORTHCOMING YEAR  Importer  Manufacturer
9b. Date Issued 9b 16. CERTIFICATE OF PRODUCT 16. For importers / manufacturers / exporters only
(one time submission) REGISTRATION (CPR) / (one-time submission)
10. DTI / SEC / CDA 10a PICTURE/S OF DDP/S 16a  16b Picture of DDPs 
Certificate & Articles of Inc. 16a. CPR Box Label Picture 
10a. Registration No. 16b. Pictures DDP/S Package Insert 
10b. Validity 10b 17. ENTITY’S PROFILE 17. (one-time submission) 
(one-time submission depending (duly authenticated)
on validity)
11. Current GIS (for 11 18. ORGANIZATIONAL 18. with name, positions and pictures of officers
corporations only) Dated STRUCTURE (duly authenticated) (one time submission) 
12a 19. LOCATION / VICINITY MAP 19. (one-time submission)
12. MAYOR’S PERMIT  Office  Warehouse
12b 20. FLOOR PLAN/LAY-OUT TO 20. (one-time submission)
12a. MP No. HIGHLIGHT STORAGE AREA  Office  Warehouse
12b. Official Receipt No. 12c 21. PICTURE OF DRUG ENTITY 21. Front View with signage (one-time submission)
12c. Date Issued /Valid Until  Office  Warehouse
13. DOH / FDA LTO 13a 22. PROOF OF OWNERSHIP / 22. (one-time submission)
13a. LTO Certificate & No. LEASE CONTRACT  Office  Warehouse
13b. Official Receipt No. 13b 23. PICTURE OF CONTROLLED 23. (one-time submission)
13c. Date Issued/ Valid Until SUBSTANCE’S STORAGE AREA 
(one-time submission 13c 24. LATEST SEMI-ANNUAL 24.
depending on validity) REPORT SUBMITTED 
BOC ACCREDITATION 14a 25. TRANSACTION REGISTER 25.
CERTIFICATE WITH UPDATED RECORDING 
14b 26 LATEST S-LICENSE ISSUED
RECORDING 26a
(For importers / exporters only)
26a. S License No.
14a. BOC No.
14c 26b Validity 26b
14b. Official Receipt No.
14c. Date issued/ Valid Until
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 Entity 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.

________________________________________________________________________ ___________________________________________________________________________
Printed Name and Signature of Head of Office Printed Name, Signature of Authorized Pharmacist/Signatory
 AUTHORIZATION

Date :

PDDGen. ISIDRO S LAPEÑA (Ret), PhD, CSEE

Director General
Philippine Drug Enforcement Agency
NIA Northside Road, National Government Center, Brgy.
Pinyahan, Quezon City

Attention: DIR III HELEN MAITA E. REYES, Rph, MBA, MGM

Director, Compliance Service

Dear Ma’am,

I hereby authorize the bearer whose signature appear below to:

(NAME)

________: file renewal application with requirements

________: claim/pick-up License to Handle (LTH)

our in my behalf.
(Type of S/P License)

I shall be accountable for any violation/s that might be committed for the said transaction.

_________________________________
Printed Name and Signature of Authorized Signatory/pharmacist

_________________________________
Printed Name and Signature of Authorized Representative

_________________________________
Original and Photocopy of valid Company/Entity’s ID presented