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130 Pesticide Dealership

FPA pesticide application form for pesticide dealership

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

FPA FORM NO. 130
NOT FOR SALE

APPLICATION FOR PESTICIDE DEALERSHIP LICENSE
_________ Agricultural _________ Wood Preservative ___________ Household
PLEASE READ INSTRUCTION. Answer all questions completely. Be sure to write additional comments as
necessary. This license will be automatically revoked if you are found in possession of or selling unregistered
products or 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 Representative: ____________________________________________________________________
5. Type of Ownership:
__________ Single Proprietorship
__________ Partnership
6. Capitalization:

____________ Corporation
____________ Cooperative

P________________________

7. Name of Personnel who attended Accredited Professional Pesticide Adviser (APPA) or Agro-Dealers/
Retailers training:
Name, Date and
Place of Training

Name
______________________________
______________________________

I.D. No.

____________________________
____________________________

_________
_________

Expiry Date
_____________
_____________

8. List of Pesticide Products:
______________________
______________________
______________________
______________________

_____________________________
_____________________________
_____________________________
_____________________________

_________________________________
_________________________________
_________________________________
_________________________________

F/P Dealer
Page –2
9. List of Outlets (Business Name & Address):
_______________________________________ _____________________________________________________
_______________________________________ _____________________________________________________
_______________________________________ _____________________________________________________
10. Physical Facilities:
Warehouse
___________________ Rent
___________________ Own
___________________ Others
Location:
Warehouse
_________________________
_________________________
_________________________

Capacity
__________________
__________________
__________________
Residential Area
Commercial Area
Agricultural Area

Store
Capacity
_______________ Rent ___________________
_______________ Own ___________________
_______________ Others ___________________

_________________________ Residential Area
_________________________ Commercial Area
_________________________ Agricultural Area

11. What safety features do you have in the store/warehouse? Enumerate.
(Use separate sheet if necessary). :
____________________________________________________________
12. Number of personnel employed:
_______________________________________________________________
13. 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.
I 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 ________________
MUN./CITY OF ________________
SUBSCRIBED AND SWORN TO before me this _______ day of ___________________ 20
________
at ___________________________________, Philippines. Affiant exhibited to me his/her Resident
Certificate No. _______________ i ssued on ____________ , ___________ at _______________________
Philippines.

Doc. No. : ____________
Page No. : ____________
Book No. : ____________
Series Of. : ____________

Original bears P15.00 documentary stamp.

NOTARY PUBLIC
Until December 31, ________
PTR No. ___________
 
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