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P-150 Pesticide Importer/Indentor/Trader/Exporter License
FPA pesticide application form for importer/indentor/trader/exporter licence
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-150
APPLICATION FOR PESTICIDE IMPORTER/INDENTOR/TRADER/EXPORTER LICENSE
______ Agricultural
______ Household
______ New
______ Renewal
1. Business Name of Applicant
__________________________________________________
__________________________________________________
FPA USE ONLY
Date Submitted: ___________
Address: __________________________________________
Received by: _____________
__________________________________________________
O.R. No.: ________________
__________________________________________________
Amount Paid:_____________
__________________________________________________
Date: ___________________
Tin No.: __________________________________________
Tel. No.: __________________________________________
2. Mechanism of Payment
3. Type of Activity
Letter of Credit
Others, specify
Importer
Indentor
Trader
Exporter
4. Pesticide Importer (Use additional sheets if necessary)
Technical/Formulated
Name & Address
of Supplier
Country of
Origin
5. In country major warehouse point(s) (Use additional sheets if necessary)
Location/Address
Capacity
6. Form and package importation is disposed/passed on the immediate recipient:
As is
Repacked
Technical Material
Formulated Products
7. I hereby agree to furnish FPA copies of importation documents after
shipment/importation of pesticide/agricultural chemical not later than 15 days arrival of
shipment/importation.
Applicant’s :
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/mpl
fn:p150
09/2005
NOTARY PUBLIC
Until December 31, _______
PTR No. _________________
