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FPA application form for export certificate
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APPLICATION FOR EXPORT CERTIFICATE
1 of 1
Reminder: Please fill out the form completely and legibly
(to be filled out by FRD)
1. APPLICANT INFORMATION
a. Business Name
Exporter License No.
b. Business Address
2. EXPORTATION DETAILS
a. Port of Discharge
b. Estimated Time of Departure
d. Cosignee’s Address
3. PRODUCT DETAILS
a. Product name
b. Quantity (MT, Liters etc.)
c. Unit Price/MT (in USD)
d. Total amount
e. Payment term
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 _______________________,
(Original should bear documentary stamp)