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License to Operate as Fertilizer Handlers
FPA license application form to operate as fertilizer handler
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Annex 19
Form no.
2
Date
09.24.2018
Author
S.A.Binobo
Approved by
J.B.Lansangan
Page
APPLICATION FOR LICENSE TO OPERATE AS
FERTILIZER HANDLER
FPA-FRD-F03
Revision no.
Document title
1 of 2
Reminder: Please fill out the form completely and legibly
Contact person
Contact number
E-mail address
New
Renewal
1.
a.
:
:
:
License no.:
Expiry date:
Manufacturer
Processor
Formulator
Importer
Indentor
Exporter
Distributor
Bulk handler
Others
Date Received
Date Processed
Application No.
Amount Paid
OR No.
OR Date
(to be filled out by FRD)
COMPANY INFORMATION
Name of Company :
TIN No.
Business Address
Head office
Regional/Provincial office
:
:
:
:
b.
Type of Ownership : Attach SEC Registration and Articles of Incorporation/Board Resolution of Corporation/Cooperative
and SPA if representative
Single Proprietorship
Corporation
Partnership
Cooperative
2.
BOARD OF DIRECTORS AND MANAGEMENT
Name
Position
3. CAPITALIZATION (Attach balance sheets and financial statements for the last 3 years and latest Income Tax Returns)
Write amount with denomination:
4.
5.
6.
For INDENTORS, list of Foreign Suppliers represented in the Philippines
Foreign Suppliers
Location
List of Distributors and Dealers given by region
Distributors/Dealers
Location
Enumeration of brands/grades/fertilizer materials you manufacture/import/indent/distribute/export
Note: Use separate sheets if necessary
Annex 19
Form no.
7. List of Physical Properties (Owned/Rented)
Name of Facility (indicate if Plant, Warehouse or Store)
Capacity
Revision no.
2
Date
09.24.2018
Author
S.A.Binobo
J.B.Lansangan
Page
APPLICATION FOR LICENSE TO OPERATE AS
FERTILIZER HANDLER
FPA-FRD-F03
Approved by
Document title
2 of 2
Location
8. Enumeration of Safety Features in plant/store/warehouse
9. Employee
Department
No. of Personnel
Note: Use separate sheets if necessary
10. In case of Distributors, are you capable of extending credit to your dealers?
No
Yes
Approximate loan ceiling per annum:
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.
NOTARY PUBLIC
Doc. No.
Until
Page No.
PTR NO.
Book No.
Series of
(Original should bear documentary stamp)
