SEARCH
Philippine Government Forms All in One Location
Tweet
Share
P-160 Pesticide Area Distributor/Distributorship License
FPA pesticide application form for area distributor/distributorship license
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-160
APPLICATION FOR PESTICIDE AREA DISTRIBUTOR /
DISTRIBUTORSHIP LICENSE
FPA USE ONLY
1. Business Name of Applicant
___________________________________________________
___________________________________________________
Address: ___________________________________________
___________________________________________________
Date Submitted: ___________
Received by: _____________
O.R. No.: ________________
Amount Paid:_____________
Date: ___________________
___________________________________________________
Tel. No.: ___________________________________________
2. Capitalization (Attach most recent financial statement)
__________________________________________________________________________
3. Supplier(s) Represented (Use additional sheets if necessary)
__________________________________________________________________________
4. List of Dealers (Use additional sheets if necessary, updated yearly)
__________________________________________________________________________
5. Major Warehouse Points (Give exact address: Use attached form)
__________________________________________________________________________
6. Product Listing (Use additional sheets if necessary, updated yearly)
__________________________________________________________________________
7. Name of Personnel with training in Pesticide Safety (Use additional sheets if necessary)
__________________________________________________________________________
8. Applicant’s Representative:
Signature:
______________________________
Name (Print): ______________________________
Title:
______________________________
REPUBLIC OF THE PHILIPPINES)
PROVINCE OF _______________)S.S.
MUN/CITY OF ________________)
SUBSCRIBED AND SWORN TO before me this ________ day of __________
________ at _______________ , Philippines, affiant exhibited to me his/her Residence
Certificate No. _______________ issued on ____________ at _______________, Philippines.
Doc. No. : _______________
Page No.: _______________
Book No.: _______________
Series of: _______________
Original bears P15.00 documentary stamps.
/NNR/rvc
fn:p160
04/2002
NOTARY PUBLIC
Until December 31, _______
PTR No. _________________
