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Export Certificate

FPA application form for export certificate

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1

Date

09.25.2018

Author

S.A.Binobo

Approved by

J.B.Lansangan

Page

APPLICATION FOR EXPORT CERTIFICATE

FPA-FRD-F13

Revision no.

Document title

1 of 1

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

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:
:

Date Received
Date Processed
Application No.
Amount Paid
OR Number
OR Date
(to be filled out by FRD)

1. APPLICANT INFORMATION
a. Business Name
:
Telephone number
Exporter License No.
TIN No.
b. Business Address

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:
:

Expiry date:

:

2. EXPORTATION DETAILS
a. Port of Discharge
b. Estimated Time of Departure
c. Consignee
d. Cosignee’s Address
3. PRODUCT DETAILS
a. Product name
:
CPR No.
b. Quantity (MT, Liters etc.)
c. Unit Price/MT (in USD)
d. Total amount
e. Payment term

:
:
:
:

:
:
:
:
:

Expiry date

:

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)
 
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