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1B Application for Buying Station's License

PhilFIDA application form for buying station's license

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: FIDA FORM 1B
2004

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Republic of the Philippines
Department of Agriculture
FIBER INDUSTRY DEVELOPMENT AUTHORITY
Quezon City
No.
: ______
Date Applied
: ______
Date Released
: ______
License Expires on :______
Control

APPLICATION FOR BUYING STATION LICENSE
(Original)
The Administrator
FIDA, Quezon City
Thru: The Fiber Regional Director
Region __________
Madam :
I have the honor to apply for a Buying Station License pursuant to PD 652 in relation to
Executive Order Nos. 709 and 116, and in accordance with the provisions of FIDA Revised
Administrative Order No. 1.:
1.

Name of Buying Station : ____________________________________________________
Address : _________________________ Tel. No. ______ Fax No. ______ E-mail _______
Name of Mother Company : __________________________________________________
Address : __________________________ Tel. No. ______ Fax No. ______ E-mail ______
Metro Mla. (if any) ________________ Tel. No. ______ Fax No. ______ E-mail ______

2.

That I, _______________________________, ________________________ (Nationality)
residing at ________________________________ with TIN: _______________________
represent the above buying station as
Manager
Warehouseman
Others _____;

3.

That I am dealing with ______________________ fiber/s;

4.

That I am submitting the following document/s to support my application :
Certification from Mother Company

Mayor’s Permit/Tax Clearance

5.

That I shall allow FIDA authorized representative to have free access to my establishment;

6.

That I shall submit monthly statistical information/data required by FIDA;

7.

That I have _____ (number) employee/s of whom _____ (number) is/are male/s and
______ (number) is/are female/s with an average of _____ (number) dependent/s per
employee;

FIDA FORM 1B
2004

8.

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That I and my personnel shall at all times comply with the FIDA rules and regulations.

I hereby certify under the penalty of law to the veracity of the above statements and that
the application was prepared by me or my authorized representative under my personal direction.

_______________________________________
Printed Name and Signature of Applicant
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
REPUBLIC OF THE PHILIPPINES)
PROVINCE OF _______________ ) S.S.
Municipality of _______________ )

SUBSCRIBED AND SWORN to before me on this __ day of __________200__ affiant
exhibiting to me his/her Community Tax Certificate No. ________ issued at ___________ on
__________ 200___.
Notary Public
Until December 200 ___
Doc. No. _____
Book No. _____
Page No. _____
Series of _____
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _

CE R T I F I C A T I O N
(To be filled out by the Licensing Personnel)
I hereby certify that the application of _____________________________ for Buying
Station license has been reviewed/verified by me and that all the requirements are duly complied
with.
Application fee of ____________________________________(P____________) and
license fee of
____________________(P___________) for a total of _____________________ (P__________)
was paid under OR No. _____________dated _____________.
Remarks: __________________________________________________________________.

Attested by :

Verified by:

_______________________
Fiber Regional Director

______________________
Printed Name and Signature
__________________________

Designation

fn: Application for Buying Station License (Original – October 2004)

LICENSE FORM 02
(For Original & Renewal)
2004

Republic of the Philippines
Department of Agriculture
FIBER INDUSTRY DEVELOPMENT AUTHORITY
Quezon City
_______________
Date of Inspection

REPORT ON RE-INSPECTION/RE-EVALUATION OF FACILITIES/PREMISES
(BUYING STATION & LOCAL TRADER (CLASS B, C & D)
1. Name of Establishment/Licensee ________________________________________________
2. Address: ______________________________________ IS/Reg. Mark: _____ Class: _____
3. Location of warehouse: _______________________________________________________
Facilities/Premises/Equipment:
a. With partition to segregate fiber in case other
commodities are stored in the same bodega
b. Clean storage area for fiber with hanging poles/other
similar facilities for drying fiber
c. With concrete flooring storage
d. Weighing Device: (if defective - 0%)
`
TOTAL -

Score

Standard

_____

30%

_____
_____
_____

20%
30%
20%
100%

4. FIDA Signboard : (Complied/Not complied) ______________ ( To be complied within 60
days for New Licensee
5. Price Bulletin (Complied/Not complied) _________________________________________
I/We hereby certify that the foregoing inspection report was based on the actual inspection
conducted by undersigned FIDA representative on the facilities/premises of the above
establishment/licensee.
Remarks/Recommendations: ___________________________________________________

Conforme : __________________
Operator/Manager

Re-inspected/Re-evaluated by : _____________________
Print Name and Signature

_____________________
Designation

Note:
Establishments with total rating below 75% shall not be issued licenses

fn: Report of Inspection (Buying Station, Local Trader, Class B,C,D - October 2004)
 
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