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Annex 1 Application form CHRDR-Water
FDA application form for water purification devices/system
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Revision No. 01 Date Effective: 01 January 2018
APPLICATION FOR REGISTRATION OF WATER PURIFICATION
DEVICES/SYSTEM
Name of Manufacturer/Importer/Distributor: _____________________________________________
Office Address: ____________________________________________________________________
Plant Address: _____________________________________________________________________
Tel. No. _______________Telefax No. ___________________ Email Address: _________________
Company TIN: _____________________________________________________________________
Name of Company Representative: _____________________________________________________
Position/Designation: ________________________________________________________________
If renewal: CHRDR No. ______________________________________________________________
For Single Proprietorship or Partnership, list the name of owner and/or partner:
______________________________________
________________________________________
For Corporation, list the name of:
INCORPORATORS
OFFICERS
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
PRODUCT
POSITION
________________________
________________________
________________________
________________________
________________________
________________________
BRAND
DESCRIPTION
___________________
___________________
___________________
___________________
___________________
___________________
CLAIMS
(Use additional sheet if necessary)
_______________
_______________
_______________
_______________
______________
______________
______________
______________
__________________
__________________
__________________
__________________
___________________
___________________
___________________
___________________
I hereby certify that all the information given above and all other data in connection with this
application are true and correct. I understand that any misrepresentation or false information will be
ground for outright rejection of my application for registration of water purification device(s)/system(s).
I am also authorizing representatives from CDRRHR-PRSDD to conduct verification of all the
documents attached herewith and inspection of the above-stated products as may be deemed necessary.
Furthermore, I understand that my application will not be processed until after I have completely
submitted all the requirements enumerated in this application form.
____________________________________________________
Signature of Company Representative over Printed Name
_________________________
Date
