Dealership

FPA application form for dealership

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Form no.
Revision no.

09.24.2018

Author

S.A.Binobo

Approved by

J.B.Lansangan

Page

APPLICATION FOR DEALERSHIP

2

Date

Document title

FPA-FRD-F07

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.

:
Fertilizer

Both Fertilizer and Pesticide

Pesticide

License no.:
Expiry date:

Other Agricultural Chemicals

Amount Paid
OR Number
OR Date
(to be filled out by FRD)

1. BUSINESS INFORMATION
a. Name of Company
:
a. TIN no.
b. Telephone No.
c. Business Address
Head office
Branches

:
:
:
:
:

b. Type of Ownership
Single Proprietorship
Partnership
c. Name of Owner

Corporation
Cooperative

:
(Surname)

d. Name of Authorized Representative

(First name)

(M.I.)

:

2. CAPITALIZATION
Write amount with denomination :
3.

Name of Personnel who attended Accredited Safety Dispenser’s (ASD) Training
Name
Date
Place

Rating

Note: Use separate sheets if necessary

4.

List of Distributors and Dealers given by region
Distributors/Dealers

Note: Use separate sheets if necessary

5.

List of registered fertilizers and pesticides being sold

Note: Use separate sheets if necessary

Location

Annex 20

Form no.
Revision no.

7.

J.B.Lansangan

Page

Capacity

S.A.Binobo

Approved by

6. List of Physical Facilities (Owned/Rented)
Name of the Facility (indicate if
plant/warehouse/store)

09.24.2018

Author

APPLICATION FOR DEALERSHIP

2

Date

Document title

FPA-FRD-F07

2 of 2

Location

Enumeration of Safety Features in plant/store Warehouse

8. Other information
a. Number of personnel employed
b. Did you have any training in pesticide handling?
c. Are you capable of extending credit to farmers in your area?

No
No

Yes
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)