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License to Repack Fertilizers
FPA application form for license to repack fertilizer
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Annex 20
Form no.
Revision no.
09.24.2018
Author
S.A.Binobo
Approved by
J.B.Lansangan
Page
APPLICATION FOR DEALERSHIP
2
Date
Document title
FPA-FRD-F07
1 of 2
Reminder: Please fill out the form completely and legibly
Contact person
Contact number
E-mail address
New
Renewal
:
:
Date Received
Date Processed
Application No.
:
Fertilizer
Both Fertilizer and Pesticide
Pesticide
License no.:
Expiry date:
Other Agricultural Chemicals
Amount Paid
OR Number
OR Date
(to be filled out by FRD)
1. BUSINESS INFORMATION
a. Name of Company
:
a. TIN no.
b. Telephone No.
c. Business Address
Head office
Branches
:
:
:
:
:
b. Type of Ownership
Single Proprietorship
Partnership
c. Name of Owner
Corporation
Cooperative
:
(Surname)
d. Name of Authorized Representative
(First name)
(M.I.)
:
2. CAPITALIZATION
Write amount with denomination :
3.
Name of Personnel who attended Accredited Safety Dispenser’s (ASD) Training
Name
Date
Place
Rating
Note: Use separate sheets if necessary
4.
List of Distributors and Dealers given by region
Distributors/Dealers
Note: Use separate sheets if necessary
5.
List of registered fertilizers and pesticides being sold
Note: Use separate sheets if necessary
Location
Annex 20
Form no.
Revision no.
7.
J.B.Lansangan
Page
Capacity
S.A.Binobo
Approved by
6. List of Physical Facilities (Owned/Rented)
Name of the Facility (indicate if
plant/warehouse/store)
09.24.2018
Author
APPLICATION FOR DEALERSHIP
2
Date
Document title
FPA-FRD-F07
2 of 2
Location
Enumeration of Safety Features in plant/store Warehouse
8. Other information
a. Number of personnel employed
b. Did you have any training in pesticide handling?
c. Are you capable of extending credit to farmers in your area?
No
No
Yes
Yes
Approximate loan ceiling per annum:
CONSENT TO PROCESS AND SHARE DATA
In compliance with the Data Privacy Act, I hereby give my consent to the Fertilizer and Pesticide Authority to share my contact details
to the public for whatever legal purpose it may serve.
Signature over Printed Name of the Contact Person
I HEREBY CERTIFY that the foregoing data and information including those in the annexes hereof are true and correct to the
best of my knowledge.
IN WITNESS WHEREOF, I have hereunto set my hand this _____day of ______year _________ at __________, Philippines.
Name and Signature of Firm’s President, Manager or
Authorized Representative
REPUBLIC OF THE PHILIPPINES
PROVINCE OF ______________________
MUNICIPALITY/CITY OF ______________
SUBSCRIBED AND SWORN TO before me this _____ day of ________ year _______ at ___________________, Philippines. Affiant
exhibited to me his/her Residence Certificate No. ______________ issued on _________________ at _______________________,
Philippines.
NOTARY PUBLIC
Doc. No.
Until
Page No.
PTR NO.
Book No.
Series of
(Original should bear documentary stamp)
