SEARCH
Philippine Government Forms All in One Location
Tweet
Share
Payment Assessment Slip Sales Promo
FDA medical device registration assessment slip form for payment sales promo
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Cashier’s Copy
CDRRHR’s Copy
QWP-CDRRHR/LRD-07 Annex 01
Rev. 01 Date Effective: 18 October 2017
QWP-CDRRHR/LRD-07 Annex 01
Rev. 01 Date Effective: 18 October 2017
DATE: ____________________
DTN:
Applicant Company: _______________________________________________________
Address/Email/Tel No.___________________________________________________________
Promo Title: _______________________________________________________________________
DATE: ____________________
DTN:_______________
Applicant Company: _______________________________________________________
Address/Email/Tel No.___________________________________________________________
Promo Title: _______________________________________________________________________
.
.
.
Permit No.:
.
Permit No.:
COVERAGE
NATIONAL CAPITAL REGION only or in several
regions including NCR and NATIONWIDE
More than (1) region but excluding NCR
Several provinces/cities/municipalities within a
single region
Single province / city /municipality
Home Solicitation
Sale
PhP 760.00
Sales Promotion
PhP 1,010.00
760.00
560.00
760.00
560.00
260.00
260.00
COVERAGE
NATIONAL CAPITAL REGION only or in several
regions including NCR and NATIONWIDE
More than (1) region but excluding NCR
Several provinces/cities/municipalities within a
single region
Single province / city /municipality
Home Solicitation
Sale
PhP 760.00
Sales Promotion
PhP 1,010.00
760.00
560.00
760.00
560.00
260.00
260.00
Amount of fees for sales promotions (except for discount scheme type of promotion shall be in
accordance with the schedule enumerated hereunder or in accordance with geographical areas,
whichever is higher)
Fee
Amount of Prizes
PhP
50,000.00
PhP
260.00
50,001.00 – 150,000.00
510.00
150,001.00 – 300,000.00
1,010.00
300,001.00 – 500,000.00
2,020.00
500,001.00 – 1,000,000.00
3,030.00
Above 1,000,000.00
5,050.00
Amount of fees for sales promotions (except for discount scheme type of promotion shall be in
accordance with the schedule enumerated hereunder or in accordance with geographical areas,
whichever is higher
Fee
Amount of Prizes
PhP
50,000.00
PhP
260.00
50,001.00 – 150,000.00
510.00
150,001.00 – 300,000.00
1,010.00
300,001.00 – 500,000.00
2,020.00
500,001.00 – 1,000,000.00
3,030.00
Above 1,000,000.00
5,050.00
310.00
310.00
Amendment/Extension
_______________________________________
Amendment/Extension
PAYMENT DETAILS
EVALUATOR
Fee
: ________________________
Legal Research Fee (1%):_______________
Surcharge : ________________________
TOTAL
: ________________________
Evaluated by : ________________________
CASHIER
Amount
: ___________________________
OR Number : ___________________________
Date Issued : ___________________________
Received by : ___________________________
PAYMENT DETAILS
EVALUATOR
Fee
: ________________________
Legal Research Fee (1%):_______________
Surcharge : ________________________
TOTAL
: ________________________
Evaluated by : ________________________
CASHIER
Amount
: ___________________________
OR Number : ___________________________
Date Issued : ___________________________
Received by : ___________________________
RECEIPT DETAILS
Name
: ________________________________________
Signature
: ________________________________________
RECEIPT DETAILS
Name
: ________________________________________
Signature
: ________________________________________
(DTI-DOH-A.O. No. 1 s. 2000)
(DTI-DOH-A.O. No. 1 s. 2000)
