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Annex E
ACCOUNTING SECTION’S COPY
Bureau of Food and Drugs
Policy, Planning, and Advocacy Division
A S S E S S M E N T S L I P
FOOD
DATE:
Bureau of Food and Drugs
Policy, Planning, and Advocacy Division
A S S E S S M E N T S L I P
FOOD
RSN:
Applicant Company
Address/Tel no.
LTO No./Validity
DATE:
: _______________________________________________________
: _______________________________________________________
: _______________________________________________________
Manufacturer Distributor/Wholesaler
PRODUCT INFORMATION
Brand name and Product
Name
Product Classification
(Category/Code)
Importer
Exporter
Wholesaler
RSN:
Applicant Company
Address/Tel no.
LTO No./Validity
: _______________________________________________________
: _______________________________________________________
: _______________________________________________________
Manufacturer Distributor/Wholesaler
PRODUCT INFORMATION
Importer
:
Brand name and Product
Name
Product Classification
(Category/Code)
List of Products
:
List of Products
:
Number of Products Applied
:
Packaging Types and Sizes
:
Packaging Types and Sizes
:
Registration Number (FR)
: __________________
Registration Number (FR)
: __________________
Applicant Company
:
Applicant Company
:
Manufacturer
:
Manufacturer
:
Repacker
:
Repacker
:
Distributor
:
Distributor
:
Others (Pls. specify)
:
Others (Pls. specify)
:
Number of Samples
: __________________
Number of Samples
: __________________
Wholesaler
:
Number of Products Applied
Exporter
:
Validity: ___________________________________
Loose Labels:_______________________________
APPLICATION DETAILS
Application Type
Initial
Renewal
Renewal with Surcharge
Re-application ( OLD RSN:_______________)
No. of CPR Validity Applied for (year/s)
OTHER REQUESTS
Amendment of CPR
Re-issuance/Reconstruction of CPR
Referral to ACB
Category
I
Category
II
Food
Supplement
Provisional Permit to Market (PPM)
Export Certificate
Others, pls. specify
Validity: __________________________________
Loose Labels:_______________________________
Bottled
Water
Application Type
Initial
Renewal
Renewal with Surcharge
Re-application ( OLD RSN:_______________)
No. of CPR Validity Applied for (year/s)
OTHER REQUESTS
Amendment of CPR
Re-issuance/Reconstruction of CPR
Referral to ACB
Category
I
Category
II
:
:
:
:
:
:
:
:
EVALUATOR
Fee
Surcharge
TOTAL
Evaluated by
CASHIER
Amount
OR Number
Date Issued
Received by
:
:
:
:
RECEIPT DETAILS
Name
:
Name
:
Signature
:
Signature
:
KJFSLFJ ASKFJ ALDF JLAFJ LSKDJF LAKSJDFLJ ASKDFJ ALSD
Food
Supplement
Provisional Permit to Market (PPM)
Export Certificate
Others, pls. specify
PAYMENT DETAILS
CASHIER
Amount
OR Number
Date Issued
Received by
RECEIPT DETAILS
KJFSLFJ ASKFJ ALDF JLAFJ LSKDJF LAKSJDFLJ ASKDFJ ALSD
:
APPLICATION DETAILS
PAYMENT DETAILS
EVALUATOR
Fee
Surcharge
TOTAL
Evaluated by
:
:
:
:
:
Bottled
Water
PAICS COPY
ACCOUNTING SECTION’S COPY
Annex E
