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Imported Fertilizer Product Registration
FPA registration application form for imported fertilizer product
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Annex 17
Form no.
Revision no.
2
Date
09.07.2018
Author
S.A.Binobo
J.B.Lansangan
Page
APPLICATION FOR IMPORTED FERTILIZER PRODUCT
REGISTRATION
FPA-FRD-F02
Approved by
Document title
1 of 2
Reminder: Please fill out the form completely and legibly
Contact person
Contact number
E-mail address
New
Renewal
:
:
:
Date Received
Date Processed
Application No.
Amount Paid
OR Number
CPR no.:
Expiry date:
OR Date
(to be filled out by FRD)
1.
PRODUCT INFORMATION
a.
Brand/Trade Name
b.
Type of Product (e.g. Inorganic, raw material)
c.
:
:
Guaranteed Composition of Product
(e.g. N=14%, P₂O₅=14%, K₂O=14%)
-
:
(Please indicate the proper units e.g. %w/w,%w/v, ppm)
d.
Size/Type of Packaging
:
e.
Country of Origin
:
f.
Name of Manufacturer
:
Address
Address
h.
2.
Name of Supplier
:
Address
g.
:
:
:
Trader
:
COMPANY INFORMATION
a. Name of Company
:
b. Business Address
:
Telephone no.
3.
:
TARGET USERS/CROPS
1.
8.
2.
9.
3.
10.
4.
11.
5.
12.
6.
13.
7.
14.
4. FPA ACCREDITED RESEARCHER HANDLING THE EXPERIMENT/FIELD TEST
(Surname)
(First name)
(M.I.)
Annex 17
Form no.
Revision no.
2
Date
09.07.2018
Author
S.A.Binobo
J.B.Lansangan
Page
APPLICATION FOR IMPORTED FERTILIZER PRODUCT
REGISTRATION
FPA-FRD-F02
Approved by
Document title
2 of 2
5.
a.
COST COMPONENTS AND PRICES
Unit of measure
(Please state if in metric ton, liter, etc.)
b. C&F/CIF Price (in foreign currency)
c. Peso Value
d. Customs Duty
e. Taxes
f. 3% ad valorem
g. Wharfage
h. Stevedoring & Arrastre
i. Other Landing Charges
j. Miscellaneous
Landed cost
k. Administrative/Selling cost
l. Interest Charges
m. Others (specify)
Total cost
n. Importer’s mark-up
o. Ex-warehouse Price
Note: Enumerate warehouse & corresponding ex-warehouse prices if more than one.
CONSENT TO PROCESS AND SHARE DATA
In compliance with the Data Privacy Act, I hereby give my consent to the Fertilizer and Pesticide Authority to share my contact details
to the public for whatever legal purpose it may serve.
Signature over Printed Name of the Contact Person
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 ______year _________ at __________, Philippines.
Name and Signature of Firm’s President, Manager or
Authorized Representative
REPUBLIC OF THE PHILIPPINES
PROVINCE OF ______________________
MUNICIPALITY/CITY OF ______________
SUBSCRIBED AND SWORN TO before me this _____ day of ________ year _______ at ___________________, Philippines. Affiant
exhibited to me his/her Residence Certificate No. ______________ issued on _________________ at _______________________,
Philippines.
Doc. No.
Page No.
Book No.
Series of
NOTARY PUBLIC
Until
PTR NO.
(Original should bear documentary stamp)
