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S-License Application Form
PDEA application from for S-License
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: FM-CSVlrd-06
REPUBLIC OF THE PHILIPPINES
CITY OF
)
)
JOINT AFFIDAVIT
We,___________________and _________________ of legal ages, ________and___________, _______and _______
(Names )
(Citizenships)
(Status)
and residing at
and __________________________________________________,
(Addresses)
and employed as ___________________________________________ and ________________________________________ respectively,
(Designations)
by____________________________________________________________________________________________________________,
(Name and Address of Establishment)
after having been duly sworn in accordance with the law, do hereby depose and say:
That,________________________________________ is a [
(Name of Establishment)
] new / [
] renewal applicant for a PDEA License
to handle the following specified dangerous drug/s:
Name of Dangerous Drug/s
Purpose of Handling
Annual Projected Quantity
* (of Importation/ Exportation/
Manufacture / Repack / Recycle /
Distribute / Retail / End-use / Lab or
Research Use
- choose activity as appropriate) *
* (use extra sheet, if necessary,
and mark as annex)*
* (Importation / Exportation /
Supplier/s
Manufacture/ Distribution/
Retail/ Consumption) *
* (if for end-use / lab. use purposes,
please provide details) *
That, the above cited dangerous drug/s shall be solely used for the legitimate purpose governing the nature of the
applicant’s legitimate existence, and in no case will it be diverted to illegal purposes.
(This paragraph is applicable for applicants with late renewal and/or late submission of Semi-Annual Report only).
That our PDEA License expired on _______________________________ and our latest Semi-Annual Report (SAR) for the period
covering January to June _______ /
July to December _______ was submitted late to PDEA Compliance Service on
________________________ due to _____________________________________________________________________ (late renewal)
_____________________________________________________________________________________________________ (late SAR).
That, for and in behalf of our establishment and by virtue of this Affidavit, we hereby bind ourselves to all the
provisions of Republic Act 9165 otherwise known as the “Comprehensive Dangerous Drugs Act of 2002”, and its implementing Rules and
Regulations and assuring that such law and regulations shall be faithfully complied with;
That, we are executing this Affidavit to attest the truth of the foregoing facts, and for whatever legal intent and
purpose it may serve.
IN WITNESS HEREOF, we have hereunto set our hands this _____________day of __________________, 20______
at ______________________________________, Philippines.
Affiant
(Head/owner/GM/BM of company)
Affiant
(PDEA-Registered Pharmacist)
SUBSCRIBED AND SWORN to before me this ___________day of __________________________________, 20____at __________________________, Philippines.
Affiants personally exhibiting their [ ] Community Tax Certificate Nos. / [ ] valid Government-issued ID Nos. ___________________ and ___
issued
on______________and _____
at
and
, respectively.
Doc. No.
Page No.
Book No.
Series of
NOTARY PUBLIC
NOTE: WHEN ACCOMPLISHING THIS AFFIDAVIT, PLEASE DELETE TEXTS IN RED FONT.
FOR LATE RENEWAL AND /OR LATE SAR SUBMISSION PLEASE SUBMIT THREE (3) COPIES OF THIS AFFIDAVIT.
Rev_ 3_ May15, 2017
