Form no.

FPA-FRD-F07
Document title Revision no. 03
APPLICATION FOR DEALERSHIP Date 01.19.2022
Page 1 of 2

Reminder: Please fill out the form completely and legibly

Contact person : PATRICIO P. AGSAY JR. To be filled out by FPA

Position/Designation : STORE IN CHARGE Date Received
Contact number : 09202651696 Date Processed
E-mail address pototanfarmersmpc2yahoo.com Application No.
 New Amount Paid
 Renewal License no.: 593-2  Fertilizer OR Number
Expiry date: 04-16-2024  Both Fertilizer and Pesticide OR Date

1. Company Information
a. Company Name : POTOTAN FARMERS MULTI-PURPOSE COOPERATIVE
b. Main Office Address : MATIAS YUSAY SAN JOSE
House/Block/Lot No. Street Subdivision/Village Barangay
3 POTOTAN ILOILO 5008
District City/Municipality Province ZIP Code
c. Branch Name : POTOTAN FARMERS MULTI-PURPOSE COOPERATIVE (HARDWARE)
d. Branch Address : MATIAS YUSAY SAN JOSE
House/Block/Lot No. Street Subdivision/Village Barangay
3 POTOTAN ILOILO 5008
District City/Municipality Province ZIP Code
e. Branch Tel. No. : (033) 502-0681
f. Branch Email Address : pototanfarmersmpc@yahoo.com
g. Type of Ownership  Corporation  Single Proprietorship  Others (pls specify)
 Cooperative  Partnership
SEC/DTI/CDA Registration No.: 9520-06003401
h. Tax Identification No. : 000-250-913-00003
i. Name of Owner : PENASO MIRALYN J.
Surname First Name M.I.

2. CAPITALIZATION
Write amount with denomination :

3. Name of Accredited Safety Dispenser (ASD) assigned to the branch/store

Name Date of Training Place of Training ASD Identification No. Expiry Date
PATRICIO P. AGSAY APRIL 16, 2021 ILOILO GRAND HOTEL 593-2 04-16-24
IZNART ST, ILOILO CITY
PROPER, ILOILO CITY

(Continue on separate sheet if necessary)

4. List of registered fertilizer product/s being sold

Brand Name FPA Registration No. Name of Supplier Complete Address

(Continue on separate sheet if necessary)

5. List of Physical Facilities (Owned/Rented)

Owned / Indicate if Storage Capacity Total Floor Area
Name of Facility Complete Address Warehouse / Store
Rented (in MT or L) (in sq m)
OLD MARKET POTOTAN MATIAS YUSAY ST., POTOTAN, RENTED STORE MT 16 X 8
ILOILO
PFMPC STORAGE FACILITY MATIAS YUSAY ST., POTOTAN, OWNED WAREHOUSE L 54 X 36
ILOILO

(Continue on separate sheet if necessary)

 Form no. FPA-FRD-F07
Document title Revision no. 3
APPLICATION FOR DEALERSHIP Date 01.19.2022
Page 2 of 2

6. As a Dealer, are you capable of extending credit to the farmers in your area?
 No
 Yes Approximate loan ceiling per annum: N/A

CONSENT TO PROCESS AND SHARE DATA

In compliance with the Data Privacy Act, I hereby give my consent to the Fertilizer and Pesticide Authority to share my contact details
to the public for whatever legal purpose it may serve.
PATRICIO P. AGSAY JR.
Signature over Printed Name of the Contact Person

I HEREBY CERTIFY that the foregoing data and information including those in the annexes hereof are true and correct to the
best of my knowledge.
9th
IN WITNESS WHEREOF, I have hereunto set my hand this _____day Jan.
of ______year 2024
_________ at __________, Philippines.

PATRICIO P. AGSAY JR.

Name and Signature of Firm’s President, Manager or
Authorized Representative

REPUBLIC OF THE PHILIPPINES

PROVINCE OF ______________________
MUNICIPALITY/CITY OF ______________

SUBSCRIBED AND SWORN TO before me this _____ day of ________ year _______ at ___________________, Philippines. Affiant
exhibited to me his/her Residence Certificate No. ______________ issued on _________________ at _______________________,
Philippines.

NOTARY PUBLIC
Doc. No. Until
Page No. PTR NO.
Book No.
Series of

(Original should bear documentary stamp)