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P - 180 Commercial Applicators

FPA pesticide application forms for commercial applicators

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: REPUBLIC OF THE PHILIPPINES
OFFICE OF THE PRESIDENT

FERTILIZER AND PESTICIDE AUTHORITY

FPA Bldg., BAI Compound, Visayas Ave., Diliman, Quezon City
Tel. Nos.: 920-8573 / 920-0068 / 920-8173 / 922-3368 / 441-1601

Telefax:
920-8573
fpacentral77@gmail.com
Web site: http://fpa.da.gov.ph Email Add: fpa_77@yahoo.com
NOT FOR SALE
FPA Form No. P-180

APPLICATION FOR COMMERCIAL APPLICATORS LICENSE
Category:

______ Exterminator

______ Fumigator
___ New
___ Renewal

1. Business Name of Applicant
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Tel. No. ____________________________________________

FPA USE ONLY
Date Submitted: ___________
Received by: _____________
O.R. No.: ________________
Amount Paid:_____________
Date: ___________________

2. Business Address/es
a. Main _______________________________________________
_____________________________________________________
_____________________________________________________
b. Branch/es (Use additional sheet if necessary)
_____________________________________________________
_____________________________________________________
3. Capitalization (Attach most recent financial statement)
________________________________________________________

4. Area of Coverage
(Province, Region)
____________________

5. Activities
6. Equipment Use in Operation
Quantity
____ Importer
a. Storage ___________________________
_____________
____ User
__________________________________
_____________
__________________________________
_____________
____ Formulator
__________________________________
_____________
____ Repacker
____ Distributor
b. Actual Pesticide Applicator
_____________
____ Applicator
___________________________________ _____________
__________________________________________________________________________
7. Chemical/s Used in Operation (Use additional sheet if necessary)
Brand Name/s
Supplier/s
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
8. Name/s of FPA Certified Pesticide Applicator employed (Use additional sheets if necessary)
Name

Control/Ref. No.

Date of Training

9. PCO Association membership ((submit copy of certificate of membership)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
10. Training Seminar/s Attended (Related to Pest Control)
Title
Place & Date
No. of Hours
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
11. Years of Business
Inclusive Year
No. of Employee
Type of Operation
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
12. What safety measures/equipment do you employ in handling pesticides.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Name of Applicant:
Signature:
__________________________
Printed Name: __________________________
Title:
__________________________

I HEREBY CERTIFY, that the foregoing data and information including those in the
annexes hereof are true and correct to the best of my knowledge.
IN WITNESS WHEREOF, I have hereunto set my hand this _____________ day of
___________________________ with Community Tax Certificate No. _______________ , issued
on ______________ at _______________.

NOTARY PUBLIC
Until December 31, _______
PTR No. _______________

Original bears P15.00 documentary stamps.

/NNR/rvc
fn:p180
04/2002
 
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