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1E Application for Processor's License - Renewal
PhilFIDA renewal application form for processor's license
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FIDA FORM 1E
2004
Republic of the Philippines
Department of Agriculture
FIBER INDUSTRY DEVELOPMENT AUTHORITY
Quezon City
Control No.
: _____
Date Applied
: _____
Date Released
: _____
License Expires on : _____
APPLICATION FOR PROCESSOR LICENSE
(Renewal)
The Administrator
FIDA, Quezon City
Thru: The Fiber Regional Director
Region ________
Madam :
I have the honor to apply for the renewal of my Processor License pursuant to PD 652 in relation
to Executive Order Nos. 709 and 116, and in accordance with the provisions of FIDA Revised
Administrative Order No. 1:
1.
Name of Establishment : ___________________________________________________________
Address : __________________________________ Tel. No. _____ Fax No. _____ E-mail _____
Metro Mla. (if any) _________________________ Tel. No. ______ Fax No. _____ E-mail _____;
2.
That I, ___________________________________________, ___________________ (Nationality)
residing at _____________________________________________ with TIN : ________________
represent the above establishment as ________________________________ (Pres./Mgr./Prop.);
3
That the approved marks of my establishment are :
___________ Initial of Station ___________ Registered Mark
_________ Establishment No.
4.
That my previous license number ____ was issued on ______________ at ________________;
5.
That the estimated maximum processing capacity of my establishment is ____ kilos of ___ (kinds)
fiber/ per year;
6.
That I am submitting the following document/s to support my application;
Tax Clearance/Mayor’s Permit
7.
Annual Report of Operation the
Preceding Year
That the following are the amendment/s and/or change/s in my original application:
1._______________________________
3. _________________________________
2._______________________________
4 _______________________________
8. That I shall allow FIDA authorized representative to have free access to my bodega;
9.
10.
That I shall submit statistical information/data required by FIDA;
That I have ____ (number) employee/s of whom _____ (number) is/are male/s and ____ (number)
is/are female/s with an average of __________ (number) dependent/s per employee;
FIDA FORM 1E
2004
Page 2 of 2 pages
11. That I and my personnel shall at all times comply with the FIDA rules and regulations.
I hereby certify under the penalty of law to the veracity of the above statements and that this
application was prepared by me or my authorized representative under my personal direction.
________________________________
Printed Name and Signature of Applicant
REPUBLIC OF THE PHILIPPINES)
PROVINCE OF ________________) S.S.
Municipality of ________________ )
SUBSCRIBED AND SWORN to before me on this ___ day of_______ 200__ at _________ affiant
exhibiting to me his/her Community Tax Certificate No. ____________ issued at ________________ on
______________ 200___.
Notary Public
Until December 200 __
Doc. No. ______
Book No. ______
Page No. ______
Series of ______
_____________
Note:
or _______________________
Administrative Officer
Notarial Oath is required for Classes A, B, C and E Fiber Processors both for Original and
Renewal. Class D should be under oath to Administrative Officer.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ __ ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
CERTIFICATION
(To be filled out by the Licensing Personnel)
I hereby certify that the application of _________________________________________ for
Processor License has been reviewed/verified by me and that all requirements are duly complied with.
Application fee of _____________________________________ ( ___________ ) and license fee
of ____________________________(P __________) for a total of ___________________ (P ________)
was paid under OR No. _____________ dated ____________.
Remarks: _________________________________________________________________.
Attested by:
Verified by:
_________________________
Fiber Regional Director
__________________________
Printed Name and Signature
__________________________
Designation
fn: Application for Processor’s License (Renewal – October 2004)
LICENSE FORM 03
(For Original & Renewal)
2004
Republic of the Philippines
Department of Agriculture
FIBER INDUSTRY DEVELOPMENT AUTHORITY
Quezon City
__________________________
Date of Inspection
REPORT ON RE-INSPECTION/RE-EVALUATION OF FACILITIES/PREMISES
(PROCESSOR/MANUFACTURER)
1. Name of Establishment/Licensee ______________________________________________
2. Address : ___________________________________ IS/Reg. Mark _______ Class ______
3. Location of warehouse : ______________________________________________________
Facilities/Premises/Equipment:
Score
a. With partition to segregate fiber in case other
commodities are stored in the same bodega
b. Clean storage, classification and working
processing area for fiber with sufficient ventilation
and lighting facilities on fiber classification
c. With restriction signs such as “no smoking’,
“no plastic allowed”, etc.
d. Weighing Device: (if defective – 0%)
TOTAL -
Standard
____
30%
_____
30%
_____
_____
25%
15%
100%
4. FIDA Signboard : (Complied/Not complied) ____________ (To be complied within 60 days,
for New Licensee)
I/We hereby certify that the foregoing inspection report was based on the actual inspection conducted
by undersigned FIDA representative on the facilities/premises of the above establishment/licensee.
Remarks/Recommendations: _____________________________________________________
Conforme : _____________________ Re-inspected/Re-evaluated by: ____________________
Operator/Manager
Print Name and Signature
______________________
Designation
Note:
Establishments with total rating below 75% shall not be issued licenses
fn: Report of Re-inspection/Re-evaluation (Processor – Mfrer- original-renewal 2004)
LICENSE FORM 09
2004
Republic of the Philippines
Department of Agriculture
FIBER INDUSTRY DEVELOPMENT AUTHORITY
Region ____, __________
Annual Report of Operation
(Processor)
Name of Processor/Establishment : ________________________________________________________
Address _____________________________________________________________________________
Location of Facilities/Premises/Equipment __________________________________________________
Est. No. ______________
IS/RM_______________________
Class _____________________
1. Fiber Utilization/Processing/Manufacturing :
a. Fiber/s utilized : _______________
b. Source/s of fibers :
GBEs
Processors
Traders
Producers
c. Status of fibers utilized:
baled or inspected
certified
All - in
d. End Products :
Volume/Quality
Local
Export
DESTINATION
finished (specify)
semi-finished (specify)
2. Excess Fibers :
No. of bales _____________
No. of kilos ___________
3. Inventory :
A. Inspected fibers stocked by grade at the end of the year being reported :
GRADE
_______
_______
_______
VOLUME (kls)
________
________
________
GRADE
_______
_______
_______
VOLUME (kls.)
________
________
________
B. Ungraded fibers ________________ kilos
C. Kind and volume of other commodities stored in the same bodega:
KIND
VOLUME(kls)
KIND
_______
_______
______
_______
_______
______
_______
_______
______
4. Total volume of fiber consumed the preceding year ___________ (in kilos).
VOLUME (kls)
________
________
________
5. Name/s of employed licensed classifier/s: 1. ____________________________________________
2. ____________________________________________
Prepared by :
______ ______________________________
Signature of Establishment’s Representative
over Printed Name
Attested by :
_____________________________
Signature of FIDA Representative
over Printed Name
fn: Processor’s Annual Report of Operation (Renewal)
