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Dealership Evaluation

FPA pesticide form for dealership evaluation

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
Web site: http://fpa.da.gov.ph Email Add: fpacentral77@gmail.com
fpa_77@yahoo.com
NOT FOR SALE
APPLICATION FOR DEALERSHIP LICENSE
_______ Fertilizer
_______ Pesticide
_______ Household
_______ Wood Preservative

______ Both Fertilizer & Pesticide
______ Other Agrc’l. Chemicals

PLEASE READ INSTRUCTION. Answer all questions completely. Be sure to write additional comments
as requested. This license will be automatically revoked if you are found in possession of or selling
unregistered products or products obtained from unlicensed sources.
1. Business Name: __________________________________________________________________________
Telephone No.: __________________
2. Business Address:
a.) Main _______________________________________________________________________________
(Barrio)
(Town)
(Province)
b,) Branch/es: __________________________________________________________________________
(Barrio)
(Town)
(Province)
3. Name of Owner: _________________________________________________________________________
(Family)
(First)
(Middle)
Sex: ________
Civil Status: ____________
Age: _____________
4. Name of Authorized Representative: ________________________________________________________
5. Type of Ownership:
________ Single proprietorship
________ Partnership

________ Corporation
________ Cooperative

6. Capitalization: P _____________
7. Name of Personnel who attended Agro-dealers/ retailers training:
Name

8. List of Fertilizer and Pesticide Products:

9. List of Outlets (Business Name & Address: )

Date & Place
of Training

Rating

F/P Dealer
Page – 2
10. Physical Facilities:
Warehouse

Capacity

Store

Rent
Own
Others

Capacity
Rent
Own
Others

Store

Location:
Warehouse
Residential Area
Commercial Area
Agricultural Area

Residential Area
Commercial Area
Agricultural Area

11. What safety features do you have in the store/warehouse? Enumerate.
(Use separate sheet if necessary.) : _________________________________________________________
12. Did you have any training in pesticide handling? _____________________________________________
13. Number of personnel employed: ___________________________________________________________
14. Are you capable of extending credit to farmers in your area? Approximate loan ceiling per annum:
______________________________________________________________________________________
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 __________________
20__________ at _____________________________________________, Philippines.
__________________________________
Name & Signature of Applicant
__________________________________
(Designation)
REPUBLIC OF THE PHILIPPINES )
PROVINCE OF _________________ )
MUNICIPALITY OF _____________)
SUBSCRIBED AND SWORN TO before me this ______ day of _______________20_______
At ____________________________________________ , Philippines. Affiant exhibited to me his/her
Resident Certificate No. __________________________, issued on ________________, 20______ at
________________________________________________, Philippines.
Doc. No. : _____________
Page No. : _____________
Book No. :_____________
Series of. : _____________
Original bears P15.00 documentary stamp.

NOTARY PUBLIC
Until December 31, 20 _________
 
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