REGISTRATION OF PERSONNEL

AUTHORIZED TO USE THE ELECTRONIC DRUG PRICE MONITORING SYSTEM v3.0 (EDPMS v3.0)

Region : Date of Registration :

Province :

LTO Number :
Name of Company :
Address :
(No. Street Name Barangay City / Municipality)

Landline Number : Fax Number :

Mobile Number : E-Mail Address of Owner :
Name of Owner :
(Last Name, First Name, MI)
Company Category : Drugstore Manufacturer Distributor Hospital Pharmacy Others _______________
Public
Private

Authorized User of System

Name of User
No. Position Landline No. Mobile No. Fax No. E-Mail Address
(LN, FN, MI)
1
2
User (N)

GPS Cooridinate (For Hospital and Drugstore Only)

Latitude:
Longitude:
Approved By:

Company Registration Form 2

Name of Owner
(Signature Over Printed Name)