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PHILIPPINE DRUG ENFORCEMENT AGENCY Rm 213 (Compliance Service), PDEA Bldg., NIA Northside Road, Bgy. Pinyahan, Q.C.

1100Tel. No: 927-9702 loc. 198, 197 / Telefax: 920-8110Email: pdea_cs@yahoo.com. ph / Website: pdea.gov.ph APPLICATION SHEET (S-LICENSE) (Non Practitioners Registration - License to Handle Dangerous Drugs/ Dangerous Dr ug Preparation/s / Table I Controlled Chemical/s used inthe manufacture of drug preparations &/or their Drug Preparation/s)DATE MARK APPROPRIATE BOXES WITH NEW RENEWAL FILL OUT BLANKS. TYPE OR PRINT LEGIBLY. ONLY SIGNED FORMS WITH COMPLETE DOCUMENT S/ REQUIREMENTS WILL BE PROCESSED. S- LICENSE APPLIED FOR S1 S3 S4 S5C S5D S5-E S5-I S6 NAME OFESTABLISHMENT ESTABLISHMENT TYPE Office arehouseNATURE OFBUSINESSSECTOR Government Private BUSINESS ADDRESS ZIP CODEHSE ADDRESS ZIP CODE E-MAIL ADDRESS TEL. NO . FAX NO . Company Representative/s Information and Identification Numbers NAME OF HEAD OFOFFICENAME OF AUTHORIZEDPHARMACIST DESIGNATION DESIGNATIONHOME ADDRESS HOME ADDRESSE-MAIL ADDRESS E-MAIL ADDRESSTEL . NO. / MOBILE NO. TEL. / MOBILE NO.NATIONALITY NATIONALITY1. TIN CARD / ITR1a.

TIN1b. Date Issued(one-time submission)1a. If foreign national, passport or ACR or AEP 5. TIN CARD / ITR5a. TIN5b. Date Issued(one-time submission)5a1b 5b2. NBI CLEARANCE2a. Findings2b. Date Issued(one-time submission)2a 6. NBI CLEARANCE6a. Findings6b. Date Issued6a2b 6b3. LETTER OFAUTHORIZATIONDated(one-time submissio n)3 7. PRC ID CARD7a. Registration No.7b. Registration Date7c. Valid until7a7b7c 4. NOTARIZED JOINTAFFIDAVIT Dated4 8. PTR8a. PTR No.8b. Date Issued8a8b Company Identification Numbers / Other Information 9. TIN CARD / ITR9a. TIN9b. Date Issued(one-time submission)9a 15. PROJECTION FO RFORTHCOMING YEAR15 For importers &/or manufacturers only Importer Manufacturer 9b 16. CERTIFICATE OF PRODUCTREGISTRATION (CPR)16a. Check if submit ted16b. Quantity of CPRs submittedFor importers / manufacturers / exporters only 10. DTI / SEC / CDACERTIFICATE ONLY10a. Registration No.10b. Validity10a 16a 16b17a. PICTURE OF DDPs17b. BOX LABEL17c PACKAGEINSERT(one-time submission only )17a. For importers /manufacturers /exporters only 17b. For importers /manufacturers /exporters only 17c. For importers /manufacturers /exporters only 10b11. GIS (for corporationsonly) Dated1112. MAYORS PERMIT12a. MP No.12b. Date I ssued12c. Valid Until12a 18. COMPANY PROFILE 18. (one-ime submission) 12b 19. ORGANIZATIONALSTRUCTURE19. (one-ime submission) 12c20. LOCATION / VICINITY MAP20. (one-ime submission) 13. DOH BFAD LTO / CHDCERTIFICATE13a. BFAD LTO No. /CHD No.13b. Date Issued13c. Valid Until13a 21. FLOOR PLAN/LAYOUT TOHIGHLIGHT STORAGE AREA21. (one-ime submis sion) 13b 22. PICTURE OF DRUGESTABLISHMENT (FRONTVIEW)22. (one-ime submission) 13c 23. PICTURE OF CONTROLLEDDRUG STORAGE AREA23. (one-ime submission) 14. BOC ACCREDITATIONCERTIFICATE(For importers only)14a. BOC No. 14b. Date issued14a 24. PROOF OF OWNERSHIP /LEASE CONTRACT24 25. LATEST SEMI-ANNUALREPORT SUBMITTED25 14b 26. REGISTER WITH UPDATEDRECORDING26 27 LATEST S- LICENSEISSUED ./ S LICENSE #27 LIST OF CONTROLLED DRUGS HANDLED 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 Compa ny/Establishment and itsresponsible 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 andregulations implemented by the Philippi ne Drug Enforcement Agency. _________________________________________________________ _____________________ _________________________________ Printed Name and Signature of Head of Office Printed Name, Signature of Authoriz ed Pharmacist/Signatory Form: SLA-09

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