SEARCH
Philippine Government Forms All in One Location
Tweet
Share
Annex 1 Assessment Form
FDA manual notification of toys and childcare article form for assessment
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: CCRR’s Copy
Accounting Section’s Copy
Food and Drug Administration
A S S E S S M E N T S L I P
Food and Drug Administration
A S S E S S M E N T S L I P
HOUSEHOLD HAZARDOUS SUBSTANCES (TOYS & CHILDCARE ARTICLES)
Date: ______________________
DTN: ______________________________
APPLICATION DETAILS(Tick where applicable)
TYPE OF
PRODUCT:
Date: ______________________
Manufacturer
TYPE OF APPLICATION:
TYPE OF
PRODUCT:
TYPE OF ESTABLISHMENT:
Toys
Manufacturer
Childcare
Articles
Distributor (Importer/Exporter/
Wholesaler)
License to Operate (LTO)
License to Operate (LTO)
Initial
Renewal
Amendment
Distributor (Importer/Exporter/
Wholesaler)
TYPE OF APPLICATION:
Notification
Notification
Childcare
Articles
DTN: ______________________________
APPLICATION DETAILS(Tick where applicable)
TYPE OF ESTABLISHMENT:
Toys
HOUSEHOLD HAZARDOUS SUBSTANCES (TOYS & CHILDCARE ARTICLES)
Product Name:
SKU/Model No./Item No.:
Applicant Company’s Name
and Address:
Distributor(s):
Product Name:
SKU/Model No./Item No.:
Applicant Company’s Name
and Address:
Distributor(s):
Retailer(s):
Retailer(s):
Broker(s):
Broker(s):
Bill of Lading:
Invoice/ Packing List No.:
Container Number(s):
Initial
Renewal
Amendment
Bill of Lading:
Invoice/ Packing List No.:
Container Number(s):
PAYMENT DETAILS(To be filled by FDA Personnel)
PAYMENT DETAILS(To be filled by FDA Personnel)
EVALUATOR
EVALUATOR
CASHIER
CASHIER
Fee
:
Amount
:
Fee
:
Amount
:
Surcharge
:
OR Number
:
Surcharge
:
OR Number
:
TOTAL
:
Date Issued
:
TOTAL
:
Date Issued
:
Evaluated by
:
Received by
:
Evaluated by
:
Received by
:
RECEIPT DETAILS
Name
Signature
RECEIPT DETAILS
:
Name
:
:
Signature
:
