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1B Application for Buying Station's License - Renewal
PhilFIDA renewal 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
Page 1 of 2 pages
Republic of the Philippines
Department of Agriculture
FIBER INDUSTRY DEVELOPMENT AUTHORITY
Quezon City
Control No.
: ______
Date Renewed
: ______
Date Released
: ______
License Expires on : ______
APPLICATION FOR BUYING STATION LICENSE
(Renewal)
The Administrator
FIDA, Quezon City
Thru : The Fiber Regional Director
Region _______
Madam:
I have the honor to apply for the renewal of my 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 ______
Initial of Station ___________ Reg. Mark _____________ Est. No. ______________
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 my previous license number ________ was issued on ______________________at
__________________ and will expire on ____________________________;
4.
That I am dealing with _______________________ fiber/s;
5.
That the volume of fiber/s transacted by my establishment the preceding year was _________ kilos;
6.
That I am submitting the following document/s to support my application :
Tax Clearance/Mayor’s
Permit
Annual Report of Operation the
Preceding year
7.
That the following is/are the amendment/s and/or change/s in my original application (if any);
1. ______________________________ 3. ________________________________
2. _____________________________
4. ________________________________
8.
That I shall allow FIDA authorized representative to have free access to my bodega/establishment;
9.
That I shall submit statistical information/data required by FIDA for monitoring purposes;
10.
That I have ____ (number) employee/s of whom ____ (number) is/are male/s and ____ (number)
is/are female/s with an average of ______________________ dependent/s per employee;
FIDA FORM 1B
2004
11.
Page 2 of 2 pages
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 _____
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _____
CERTIFICATION
(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 :
________________________
Fiber Regional Director
Verified by:
____________________________
Printed Name and Signature
____________________________
Designation
fn: Application for Buying Station License (Renewal – 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%
_____
_____
_____
100%
20%
30%
20%
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)
LICENSE FORM 06
2004
Republic of the Philippines
Department of Agriculture
FIBER INDUSTRY DEVELOPMENT AUTHORITY
Region ____, _____________
Annual Report of Operation
(Buying Station)
Name of Licensed Buying Station : ________________________________________________________
Address : ____________________________________________________________________________
IS/RM : ________________
Establishment No. : _____________
Class : ___________________
Name of Mother Company : _____________________________________________________________
Address : __________________________________________ IS/RM ___________ Class _________
Location of Warehouse: _________________________________________________________________
1.
Fiber/Origin by Province:
Fiber/s
__________________________________
__________________________________
__________________________________
___________________________________
2.
District of Production
__________________________________
__________________________________
__________________________________
__________________________________
Volume of fibers bought the preceding year :
______________________________ kilos (as declared by participants)
______________________________ kilos
(as verified thru PTF/Primary Certificate by
Licensing Officer)
_______________________________
Signature Over Printed Name
Attested By:
_______________________________
Signature of FIDA Representative
Over Printed Name
fn: Annual Report of Operation(Buying Station – Renewal – October 2004)
