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Application Form - Diamond Sangkap Pinoy Seal
FDA application form for diamond sangkap pinoy seal
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: QWP-008-020-01-Annex-08
REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF HEALTH
FOOD AND DRUG ADMINISTRATION
Civic Drive, Filinvest Corporate City
Alabang, Muntinlupa City
APPLICATION FORM FOR THE DIAMOND SANGKAP PINOY SEAL
Date : ______________
Control Number : ______________
I. General Information
1. Name of Applicant/ Manufacturer : ____________________________
2. Business Address : _________________________________________
3. Telephone Number : ________________________________________
Fax Number : _____________________________________________
E-Mail : __________________________________________________
4. Plant Address :
_________________________________________________________
_________________________________________________________
II. Product Information (Staple)
1. Name of Staple :
_________________________________________________________
2. Brand Name/ s :
_________________________________________________________
3. Fortificant/s Used :
Name : __________________________________________________
Chemical Form : ___________________________________________
Source : __________________________________________________
4. Packaging Types and Sign :
_________________________________________________________
_________________________________________________________
To be submitted in duplicate and submitted to the Food and Drug
Administration, Filinvest Corporate City, Alabang, Muntinlupa City
III. Attachments : (Documents) Check if attached
1. FDA LTO/ Other Agencies’ LTO or Permit : ____________________
Validity : _________________________________________________
2. Certificate of Analysis of Fortificant in staple from FDA recognized
laboratory
____ Vitamin A in Sugar, Cooking Oil, Flour
____ Iron in Rice, Flour
____ Iodine in Salt
3. Proposed label with DSPS : __________________________________
IV. Application Fee/ Brand
O. R. Number : ___________________ Date : _____________________
Submitted by :
Name of Applicant/ Authorized Representative : ____________________
Position : _________________ Signature : ________________________
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