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S2 Application Form

PDEA S2application form for registration of medical practitioners

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PHILIPPINE DRUG ENFORCEMENT AGENCY
Compliance Service Room 213, PDEA Bldg., NIA Northside Road, Bgy. Pinyahan, Q.C.1100
Tel. No: 927-9702 loc. 197, 198 / Telefax: 920-8110
Email: cs@pdea.gov.ph / Website: pdea.gov.ph

S2 APPLICATION FORM FOR REGISTRATION OF MEDICAL PRACTITIONERS
(Physician / Dentist / Veterinarian)
Rev_4_August 1, 2017
ONLY DULY FILLED-OUT AND SIGNED FORM WITH COMPLETE REQUIREMENTS WILL BE PROCESSED
Date:
 RENEWAL  LOST
 NEW
MARK APPROPRIATELY BOXES WITH √
FOR RENEWAL APPLICANTS THRU A REPRESENTATIVE, PLEASE FILL-OUT AND SIGN AUTHORIZATION LETTER AT THE BACK HEREOF.
SURNAME
NAME
EXTENSION
(e.g. Jr., Sr.)

FIRST NAME
MIDDLE NAME
MOTHER'S MAIDEN NAME
Preferred Login Name
(NMT 10 characters)

EMAIL ADDRESS
MOBILE NO.

DATE OF BIRTH
(mm / dd / yyyy)
SEX

 Male

 Female

RESIDENTIAL
ADDRESS

CIVIL STATUS

 Single
 Married
 Annulled

 Widowed
 Separated
Others,

ZIPCODE
TEL. NO.
TEL. NO.
HOSPITAL / CLINIC

 Physician
 Veterinarian
 Dentist

PROFESSION

FAX NO.

ADDRESS
ZIPCODE

SECTOR

 Government

TEL. NO.

 Private

FAX NO.

PRESENT ORIGINAL DOCUMENTS FOR VALIDATION AND SUBMIT CLEAR PHOTOCOPY
S2 ID CARD / CERTIFICATE 1a
1a. S2 License No.
1b. Date Issued
1c. Valid Until

1

FOR LOST OF VALID
S2 ID CARD /
CERTIFICATE : Submit
AFFIDAVIT OF LOSS AND
POLICE BLOTTER

5a 5a

5
2c

5b

5b. Date Issued

5c

5c. Name of DOH Accredited Drug Testing
Center
5d. Address

5d

1 pc 2" x 2" ID picture with
white background taken not
6 later than 6 months from
application, without eyeglasses

3a

3a. PTR O.R. #
3b. Date Issued

4b

5a. Drug Test Result

2b

Note: Validity of S2 License
is harmonized with the PRC
ID Card Validity

3

DRUG TEST - DOH-DDB IDTOMIS
GENERATED REPORT

1c

2a

2a. PRC License #
2b. Date Issued
2c. Validity

PTR

4a. TIN (one time submission)
4b. Date Issued

1b

PRC ID CARD

2

TIN ID CARD / LATEST ITR / BIR TIN 4a

4 VERIFICATION SLIP / e -TIN

3b

FOR GOVERNMENT MEDICAL PRACTITIONERS: Submit CERTIFICATE OF EMPLOYMENT in lieu of PTR
and original NOTARIZED AFFIDAVIT attesting that S2 license shall be used exclusively for government
practice only. Government practitioners are exempted from registration fee.

ID PICTURE
2X2

I SOLEMNLY SWEAR that the statements made on this Application Form are true and the attached supporting documents are authentic. It is
understood that I am bound to comply with the provision of RA 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 Applicant
APPROVED BY:

PROCESSED BY:
________________________________________________
Signature Over Printed Name

DIR. III HELEN MAITA E. REYES, RPh, MBA,MGM
DIRECTOR, COMPLIANCE SERVICE

FM-CSVlrd-01 (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 Sir/Ma’am,
I hereby authorize the bearer

whose signature and/or right thumb

mark appear below, to apply for and in my behalf:
[ ] S2 license renewal /

[ ] S2 license re-application due to lost S2

for the period covering date of expiration / lost of my S2 license until

(expiry of

current PRC license), for which I have filled-out the application at the reverse side.

____________________________________
Signature of Authorized Representative

____________________________________
Signature of Applicant

___________________________________
Printed Name of Authorized Representative

____________________________________
Printed Name of Applicant

Right thumb mark
of representative

REMINDERS








NEW APPLICANT IS REQUIRED TO APPLY IN PERSON AT THE PDEA COMPLIANCE SERVICE / REGIONAL
COMPLIANCE SECTION.
UNLESS SURRENDERED, SUSPENDED OR REVOKED LICENSE SHALL BE RENEWED ON OR BEFORE
EXPIRATION DATE AFTER RENEWAL OF LICENSE FROM PRC. BRING ORIGINAL AND PHOTOCOPY OF
OFFICIAL RECEIPT (O.R.) AND CLAIM SLIP.
A SURCHARGE OF PHP 500.00 PER YEAR WILL BE IMPOSED FOR NON-RENEWAL OF LICENSE.
NOTIFY PDEA IN WRITING AT LEAST 60 DAYS IN ADVANCE FOR AN INTENTION TO DISCONTINUE/RETIRE
THE S2 LICENSE AUTHORITY GRANTED.
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.
RE-APPLICATION FOR A NEW LICENSE AND PAYMENT OF CORRESPONDING FEES.
A DANGEROUS DRUG PREPARATION IS PRESCRIBED IN A SPECIAL PRESCRIPTION FORM FOR DANGEROUS
DRUGS WITH S2 LICENSE INDICATED THEREIN UNLESS OTHERWISE EXEMPTED BY A REGULATION.
 
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