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EUP - Experimental Use Permit for Fertilizer Efficacy Trial

FPA application form for experimental use permit for fertilizer efficacy trial

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Form no.
Revision no.

2

Date

09.24.2018

Author

S.A.Binobo
J.B.Lansangan

Page

APPLICATION FOR EXPERIMENTAL USE PERMIT FOR
FERTILIZER EFFICACY TRIAL

FPA-FRD-F09

Approved by

Document title

1 of 1

Reminder: Please fill out the form completely and legibly
Contact person
Contact number
E-mail address

:
:
:

Date Received
Date Processed
Application No.

1. PRODUCT INFORMATION
a. Brand/Trade Name
:
b. Purpose
:
c. Guaranteed Composition :

Amount Paid

Initial trial

Second trial

OR Number

Label expansion

OR Date
Date Approved
EUP No.

(Please indicate the proper units e.g. %w/w, %w/v)

b. Product Classification
New Inorganic
Organic

Expiry Date

Specialty/Controlled
Soil Conditioners

Plant Growth Promoter
Biofertilizers (M.I./GMOs)

Extension Application
Extension Granted
(to be filled out by FRD)

2. COMPANY INFORMATION
a. Company name
:
b. Company address
:
c. TIN no.
:
d. Telephone no.
:
3. EFFICACY TRIAL INFORMATION
a. Brand/Trade Name
b. Test crop
c. Total amount of product needed
d. Inclusive dates for the duration of trial
e. Proposed treatment and method of application
f. Location of Trial
g. Name of Researcher/Accrediatation No.
h. Address of Researcher/Research institute/ Affliation

:
:
:
:
:
:
:
:

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.
NOTARY PUBLIC

Page No.
Book No.

Until

Series of

PTR NO.

(Original should bear documentary stamp)
 
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