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Fertilizer Warehouse Registration
FPA application form for fertilizer warehouse registration
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Annex 23
Form no.
2
Date
09.24.2018
Author
S.A.Binobo
J.B.Lansangan
Page
APPLICATION FOR FERTILIZER WAREHOUSE
REGISTRATION
Revision no.
Approved by
Document title
FPA-FRD-F05
1 of 1
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
OR Date
License no.:
Expiry date:
(to be filled out by FRD)
1.
APPLICANT INFORMATION
a. Business/Company Name
:
b. Business Address
:
c. Name of Owner
:
,
(Surname)
2.
Name of Warehouse
(First name)
(Middle Initial)
Storage Capacity for
Fertilizers
Address
Total Floor Area
for Fertilizers
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.
Until
Book No.
PTR NO.
Series of
(Original should bear documentary stamp)
