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Application Sheet for Accreditation

PDEA application form for accreditation

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

APPLICATION SHEET FOR ACCREDITATION
(As Transporter/Hauler/Carrier of Bulk Controlled Substances)
MARK APPROPRIATELY BOXES 
WITH √

RENEWAL




NEW

Rev_2_August 1, 2017

DATE:

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
NAME OF ENTITY
BUSINESS ADDRESS

ZIP CODE

TRUCK DEPOT ADDRESS

ZIP CODE

E-MAIL ADDRESS

TEL NO.

FAX NO.

ENTITY’S REPRESENTATIVE INFORMATION
NAME OF HEAD/ OWNER/OPERATOR
DESIGNATION
HOME ADDRESS
E-MAIL ADDRESS
TEL./MOBILE NO.
NATIONALITY
NBI CLEARANCE

Findings:

Date Issued:

ENTITY’S INFORMATION
1. MAYOR’S PERMIT
1a. MP No.
1b. Official Receipt No.
1c. Date Issued / Valid Until

1a.

7. DOST CALIBRATION
CERTIFICATE/TEST
REPORT (When applicable)
7a. Cert No.
7b. Date Issued
7c. Valid Until
8. NOTARIZED AFFIDAVIT OF
UNDERTAKING
SWORNED ON

1b.
1c.

7a.

9. With names, positions and pictures of
officers (one-time submission)

10. (one-time submission)

11.( (one-time submission)
 Office
 Warehouse
12.(Front view with signage
(one-time submission)
 Office
 Warehouse
13. (one-time submission)
 Office
 Warehouse
14. (one-time submission)

2. DTI/SEC/CDA CERTIFICATE
2a. Registration No.
2b. Validity

2a.

3. Current GIS (For corporations only)
Dated

3.

9.ORGANIZATIONAL STRUCTURE
(Duly Authenticated)

4. TIN CARD/ ITR
4a. TIN
4b. Date Issued
(one-time submission)
5. CONTRACT OF AGREEMENT
(Between Transporter/
Hauler/Carrier & Client)
5a. Date Issued
5b. Valid Until
6. DESCRIPTION AND
SPECIFICATION OF VEHICLES
6a. Photographs of front, back, and
side view
6b. Proof of ownership of the vehicle
(Certificate of Registration and
Official Receipt)
6c. LTO Registration No.
6d. Contract of lease and /or Deed/s
of Sale of the vehicle (if
applicable)

4a.
4b.

10. ENTITY’S PROFILE
(Duly authenticated)
11. LOCATION/ VICINITY MAP

5a.

12.PICTURE OF ESTABLISHMENT

5b.

13. PROOF OF OWNERSHIP/ LEASE
CONTRACT
14. PROVISION FOR A GARAGE
(Include sketch map and photographs)

2b.

6a. (one-time submission)


7b.
7c.
8.


6b. (one-time submission)


15. Name of Driver/s
15a. Professional Driver’s License

15a. (one-time submission)


6c.


6d. (one-time submission)


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 Trucking Company and its
responsible signatory officer is bound to comply with the provisions of R.A. 9165, Board Regulation No. 1. Series 2014and other pertinent regulations implemented by the Philippine Drug
Enforcement Agency.
_____________________________________________
Printed Name and Signature of Head/Owner/Operator

Approved by:
___________________________________________

FM-CSVlrd-20 (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:

________:

file renewal application with requirements

________:

claim/pick-up License to Handle (LTH)

(
N
A
M
E
)

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 SUCH 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 ACCREDITATION GRANTED.
WRITTEN NOTIFICATION IN CASES OF LOSS, THEFT, PILFERAGE AND OTHER ANALOGOUS
CIRCUMSTANCES DURING TRANPORT OF CONTROLLED SUBSTANCE WITHIN 48 HOURS FROM
OCCURRENCE TO PDEA COMPLIANCE SERVICE/REGIONAL COMPLIANCE SECTION, ADDITIONALLY
SUBMIT NOTARIZED AFFIDAVIT OF LOSS AND POLICE BLOTTER.
 
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