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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