Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Application for License to Operate a Blood Center (BC)/ Blood Bank (BB)

Name of BC/ BB :____________________________________________________

Address of BC/ BB :____________________________________________________
No. & Street Barangay
____________________________________________________
City/ Municipality Province Region
Telephone/ Fax No. :____________________________________________________

Head of the BC/ BB :____________________________________________________

Name of Owner :____________________________________________________

Contact Number :____________________________________________________

Classification According to
Ownership : [ ] Government [ ] Private

Institutional Character : [ ] Hospital Based [ ] Non-hospital Based

Service Capability : [ ] BC [ ] BB

Status of Application : [ ] Initial [ ] Renewal

License No.__________________
Date Issued__________________
Expiry Date__________________

Checklist of Application Documents

Please tick () the appropriate boxes under column B or C. Shaded Items are not required.

A B C
Documents For Initial For Renewal
1. Notarized Application for License to Operate a BC/ BB (this form)
Submit
2. List of Personnel (attached form)
changes only
3. Photocopies of the following:
3.1. Proof of qualification of the medical and paramedical staff
 Valid PRC ID
 Specialty Board Certificate of the medical staff
 Certificate of Training/ Record of Work Experience
3.2. Proof of employment of the medical, paramedical and administrative staff
Submit
4. List of Equipment/ Instrument (attached form)
changes only
5. Health Facility Geographic Form (Location Map)
Submit
6. Floor Layout
changes only
7. SEC/ DTI Registration (for private BC/ BB) OR
Issuance or Board Resolution (for government BC/ BB)
Submit
8. Quality Manual of BC/ BB
changes only
 A B C
Documents For Initial For Renewal
9. NVBSP Annual Blood Report
10. Certificate of Inclusion in the Regional Blood Services Network approved by the
identified Lead Blood Center in the region
Form-BSF-LTO-A
Revision:01
12/03/2014
Page 1 of 5

Acknowledgement

REPUBLIC OF THE PHILIPPINES )

CITY/ MUNICIPALITY OF _______________) S.S.

I, ______________________________, ____________, of legal age, __________, a resident of

Name Civil Status Age
___________________________________________, after having been sworn in accordance with law hereby depose
Address
and say that I am executing this affidavit to attest to the completeness and truth of the foregoing information and the

attached documents required for the licensure and regulation of blood service facilities in the Philippines pursuant to

Administrative Order No. 2008-0008 “Rules and Regulations Governing the Regulation of Blood Service Facilities”.

_________________________
Signature

Before me, this _________day of ______________ 20 in the City/ Municipality of ________________,

Philippines, personally appeared

Owner Community Tax Number Issued at/ on

_______________________________ _________________________ _________________________

known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same

is their free act and deed.

IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 20

Doc. No.______________________ NOTARY PUBLIC

Page No.______________________ My Commission Expires
Book No.______________________ Dec. 31, _______
Series of ______________________

Form-BSF-LTO-A
Revision:01
12/03/2014
Page 2 of 5
 APPLICATION AS HEAD OF BLOOD CENTER/ BLOOD BANK

The Director
Health Facilities and Services Regulatory Bureau/ DOH-Regional Office
DOH Manila/ Regional Office

Sir,

In compliance with the requirements of Republic Act (RA) No. 7719 and Administrative
Order (AO) No. 2008-0008, I have the honor to apply as head of:

_________________________________________
Name of Blood Center/ Blood Bank
_________________________________________
Address of Blood Center/ Blood Bank

I. Name of Applicant: ______________________________________________________

Landline No.: ________________________ Mobile No.: _______________________
Address: ______________________________________________________________

II. Education and Training (Use additional sheets if necessary):

Medical School/ Institution _____________________________________________
InclusiveDates/ Year Graduated ________________________________________

Specialty Board Date Certified Training Institution

PBP1
Anatomic Pathology
PBP Clinical Pathology
PBP Anatomic and
Clinical Pathology
PSHBT2
Others: Specify

III. List all Blood Centers/ Blood Banks supervised/ headed or associated with:

Name and Address of BC/ BB Working Time Work Schedule

A. As Head
B. As Associate

I hereby certify that the foregoing statements are true. I assume full responsibility that the
operation of the Blood Center/ Blood Bank is in accordance with the Rules and Regulations
pursuant to RA 7719 and AO No. 2008-0008.
______________________________
Signature over Printed Name
1
PBP – Philippine Board of Pathology
2
PSHBT – Philippine Society for Hematology and Blood Transfusion
 Date

Form-BC_BB-Head-A
Revision:01
12/03/2014
 List of Personnel

Name of BC/ BB :_________________________________________________________________________________________

Address of BC/ BB :_________________________________________________________________________________________

PRC Reg. No. Valid

Name Designation/ Position Highest Educational Attainment Signature
(If applicable) From To

Form-BSF-LTO-A
Revision:01
12/03/2014
Page 4 of 5
 List of Equipment3
Name of BC/ BB :_________________________________________________________________________________________
Address of BC/ BB :_________________________________________________________________________________________

Brand Name & Model Serial No. Quantity Date of Purchase

3 Form-BSF-LTO-A
Equipment shall be functional and present in the Blood Center/ Blood Bank applying for License to Operate. Revision:01
12/03/2014
Page 5 of 5