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P-001 Notice of intent to conduct experiment
FPA pesticide form for notice of intent to conduct experiment
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
NOTARY PUBLIC
Until December 31, _______
PTR No. _______________
