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P-License Application Form
PDEA application form for P-License
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: FM-CSVlrd-03 (page 1 of 2)
PHILIPPINE DRUG ENFORCEMENT AGENCY
Compliance Service Room 213 , PDEA Bldg., NIA Northside Road, Bgy. Pinyahan, Q.C.
1100 Tel. No: 927-9702 loc. 198, 197 / Telefax: 920-8110
Email: cs@pdea.gov.ph / Website: pdea.gov.ph
P-LICENSE APPLICATION FORM FOR ENTITY’S HANDLING CONTROLLED CHEMICALS
Rev_3_August 1, 2017
DATE:
MARK APPROPRIATELY BOXES
WITH √
NEW
RENEWAL
FILL-OUT BLANKS. TYPE OR PRINT LEGIBLY. ONLY SIGNED FORMS WITH COMPLETE DOCUMENTS/ REQUIREMENTS WILL BE PROCESSED.
FOR NEW APPLICANTS: ONLY THE HEAD OR AUTHORIZED PHARMACIST/SIGNATORY SHALL BE ALLOWED TO TRANSACT BUSINESS WITH PDEA.
FOR RENEWAL APPLICANTS THRU A REPRESENTATATIVE, PLEASE FILL-OUT AND SIGN AUTHORIZATION LETTER AT THE BACK HEREOF.
PRESENT ORIGINAL DOCUMENTS FOR VALIDATION AND SUBMIT CLEAR PHOTOCOPY
P- LICENSE APPLIED FOR
P1
P3
P4
P5C
P5-E P5- I
P5D
P5-IM
P6
NAME OF
ESTABLISHMENT
ESTABLISHMENT TYPE
Office
Warehouse
SECTOR
Government
Private
NATURE OF
BUSINESS
OFFICE / BUSINESS
ADDRESS
ZIP CODE
WHSE / PLANT ADDRESS
ZIP CODE
E-MAIL ADDRESS
TEL. NO.
FAX NO.
ENTITY’S REPRESENTATIVE INFORMATION
NAME OF HEAD OF
OFFICE
NAME OF AUTHORIZED
SIGNATORY
DESIGNATION
DESIGNATION
HOME ADDRESS
HOME ADDRESS
E-MAIL ADDRESS
E-MAIL ADDRESS
TEL. / MOBILE NO.
TEL. / MOBILE NO.
NATIONALITY
NATIONALITY
1. TIN CARD / ITR / BIR TIN
VERIFICATION SLIP / e – TIN
1a. TIN No. (one-time submission)
1b. Date Issued
(one-time submission)
2. NBI CLEARANCE
2a. Clearance with Findings
2b. Date Issued
(one-time submission)
3. LETTER OF
AUTHORIZATION ISSUED
ON (original copy)
(one-time submission)
1a If foreign national, passport or ACR or AEP
2a
2b
3
4a
6. NOTARIZED JOINT AFFIDAVIT
SWORNED ON
(original copy)
1b
4. TIN CARD / ITR / BIR TIN
VERIFICATION SLIP / e -TIN
4a. TIN No.
4b. Date Issued (one-time submission)
5. NBI CLEARANCE
5a.Clearance with Findings
5b. Date Issued
6
4b
5a
5b
ENTITY’S INFORMATION
7. TIN CARD/ ITR
7a. TIN No.
7b. Date Issued
(one time submission)
7a
13. MSDS OF CONTROLLED
SUBSTANCES HANDLED
14. PICTURE OF CONTROLLED
SUBSTANCES / LABELS
7b
13 .(one time submission)
14. For importers / exporters / manufacturer
(one time submission)
8. DTI / SEC / CDA Certificate 8a
& Articles of Inc.
8a. Registration No.
8b
15. (one-time submission)
15. ENTITY’S PROFILE
(duly authenticated)
16. ORGANIZATIONAL
16. With names, positions and pictures of officers
STRUCTURE (duly authenticated) (one-time submission)
9. Current GIS (for
corporations only) Dated
10. MAYOR’S PERMIT /
PEZA CERTIFICATE
10a. MP No. / PEZA No
10b. Official Receipt No.
10c. Date Issued/ Valid Until
17. PICTURE OF CONTROLLED 17. (one-time submission)
SUBSTANCE’S STORAGE AREA
18. (one-time submission)
18. LOCATION / VICINITY MAP
Office
Warehouse
(one-time submission)
19.
19. FLOOR PLAN/LAY-OUT TO
Warehouse
HIGHLIGHT STORAGE AREA
Front view with signage (one-time submission)
20. PICTURE OF
20.
Office
Warehouse
ESTABLISHMENT
21. (one-time submission)
21. PROOF OF OWNERSHIP /
Office
Warehouse
LEASE CONTRACT
8b. Validity (one-time
submission depending on validity)
9.
10a
10b
10c
11. BOC ACCREDITATION
11a
CERTIFICATE
(For importers / exporters only) 11b
11a. BOC No.
11b. Official Receipt No.
11c
11c. Date issued/ Valid until
12. FORECAST FOR
FORTHCOMING YEAR
(For importers &/or
manufacturers only)
22. LATEST SEMI-ANNUAL
REPORT SUBMITTED
23. TRANSACTION REGISTER
WITH UPDATED RECORDING
12
Importer
Manufacturer
22.
23.
24. LATEST P- LICENSE ISSUED
24a P LICENSE No.
24b Validity
24a
24b
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 Entity and its responsible 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 and regulations implemented by the Philippine Drug Enforcement Agency.
_______________________________________________________
Printed Name and Signature of Head of Office
_______________________________________________________
Printed Name, Signature of Authorized Signatory
FM-CSVlrd-03 (page 2 of 2)
AUTHORIZATION
Date :
Director General
Philippine Drug Enforcement Agency
NIA Northside Road, National Government Center,
Brgy. Pinyahan, Quezon City
Attention: DIR III HELEN MAITA E. REYES, RPh, MBA, MGM
Director, Compliance Service
Dear Ma’am/Sir,
I hereby authorize the bearer
whose signature appears below to:
(NAME)
________:
file renewal application with requirements
________:
claim/pick-up License to Handle (LTH)
in my behalf.
I shall be accountable for any violation/s that might be committed for the said transaction.
___________________________________________________
Printed Name and Signature of Authorized Signatory/pharmacist
______________________________________________
Printed Name and Signature of Authorized Representative
(To present/submit original/photocopy of valid Company ID)
REMINDERS
UNLESS SURRENDERED, SUSPENDED OR REVOKED LICENSE SHALL BE RENEWED. MAY RENEW THREE (3)
MONTHS PRIOR TO EXPIRATION.
A SURCHARGE OF 50% OF THE REQUIRED ANNUAL FEE, CUMULATIVELY BY YEAR NOT PAID SHALL BE
IMPOSED ON TOP OF THE CURRENT ANNUAL FEE.
NOTIFY PDEA IN WRITING AT LEAST 60 DAYS IN ADVANCE FOR AN INTENTION TO DISCONTINUE/RETIRE
THE P- LICENSE AUTHORITY GRANTED.
A PRE- RETIREMENT COMPLIANCE INSPECTION SHALL BE CONDUCTED.
WRITTEN NOTIFICATION ON LOSS OF LICENSE WITHIN 48 HOURS FROM OCCURRENCE TO PDEA
COMPLIANCE SERVICE/REGIONAL COMPLIANCE SECTION, ADDITIONALLY SUBMIT NOTARIZED AFFIDAVIT
OF LOSS AND POLICE BLOTTER.
A SEPARATE PERMIT APPROVAL IS NECESSARY PRIOR TO IMPORT/EXPORT of CPECs, UNLESS SPECIFICALLY
EXEMPTED
