Republic of the Philippines FM-CSVlrd-03

Office of the President

Rev_2_April 01, 2022
PHILIPPINE DRUG ENFORCEMENT AGENCY
Compliance Service
PDEA Bldg. NIA Northside Road, National Government Center, Barangay Pinyahan,
Quezon City 1100 | (02) 8927-9702 local 197 & 198 : (02) 8920-8110 : cs@pdea.gov.ph
pdea.gov.ph PDEA Top Stories PDEA@PdeaTopStories pdeatops tories

P-LICENSE APPLICATION FORM

(LICENSE TO HANDLE CONTROLLED CHEMICALS)

WITH √
MARK APPROPRIATELY BOXES  NEW 

RENEWAL
 DATE:
FILL-OUT ALL FIELDS, SIGN AND DATE THE FORM AND INDICATE N/A IF NOT APPLICABLE. USE BLACK OR BLUE INK ONLY.
FOR NEW APPLICANTS: ONLY THE HEAD OR AUTHORIZED PHARMACIST/SIGNATORY SHALL BE ALLOWED TO TRANSACT BUSINESS WITH PDEA.
SUBMIT CLEAR & NEAT SCANNED COPIES OF DOCUMENTS. ONLY WITH COMPLETE REQUIREMENTS WILL BE PROCESSED.
P- LICENSE APPLIED FOR P1 P3 P4 P5C P5D P5-E P5-I P5-IM P6
NAME OF
ESTABLISHMENT
ESTABLISHMENT TYPE  Office Warehouse
 NATURE OF
SECTOR  Government 
Private BUSINESS
OFFICE / BUSINESS
ZIP CODE
ADDRESS
WHSE / PLANT ADDRESS ZIP CODE

E-MAIL ADDRESS TEL. NO. FAX NO.

ENTITY’S REPRESENTATIVE INFORMATION
NAME OF HEAD OF NAME OF AUTHORIZED
OFFICE SIGANTORY
DESIGNATION DESIGNATION

HOME ADDRESS HOME ADDRESS

E-MAIL ADDRESS E-MAIL ADDRESS

TEL. NO. / MOBILE NO. TEL. / MOBILE NO.

NATIONALITY NATIONALITY
1a. Findings: 3a. Findings:
1. NBI CLEARANCE 3. NBI CLEARANCE
1b. Date Issued: 3b. Date Issued:

2.. NOTARIZED JOINT

Dated:
AFFIDAVIT SWORNED ON

ENTITY’S INFORMATION
4. DTI / SEC / CDA Certificate
& Articles of Inc. 4a. Registration No.:
10. PICTURE OF CONTROLLED 10. (one-time submission)
(one-time submission  Importer  Manufacturer  N/A
SUBSTANCES/ LABES
depending on validity) 4b. Validity:
5. Current GIS (for 11. ENTITY’S / COMPANY PROFILE 11. (one-time submission)
corporations only) 5. Dated:
(BRIEF & CONCISE)  Submitted  N/A
Office:
6a1. Permit No.: 12. (one-time submission)
6a2. Date Issued: 12. ORGANIZATIONAL STRUCTURE
 Submitted  N/A
6a3. Valid Until:
6a4. Official Receipt No.:
6. MAYOR’S PERMIT/
6a5. Date Issued 13. (one-time submission)
PEZA CERTIFICATE/ 13. LOCATION / VICINITY MAP
Warehouse/ Plant:  Office  Warehouse  N/A
BOI
6b1. Permit No.:
6b2. Date Issued:
6b3. Valid Until: 14. (one-time submission)
14. PICTURE OF ESTABLISHMENT
6b4. Official Receipt No.:  Submitted  N/A
6b5. Date Issued
15. FLOOR PLAN/LAY-OUT TO 15. (one-time submission)
7a. BOC No.:
7. BOC ACCREDITATION HIGHLIGHT STORAGE AREA  Office  Warehouse  N/A
CERTIFICATE 16. PICTURE OF CONTROLLED 16. Front View with signage (one-time submission)
7b. Date issued:
(For importers / exporters SUBSTANCE’S STORAGE AREA  Office  Warehouse  N/A
only) 17. PROOF OF OWNERSHIP / LEASE 17. (one-time submission)
7c. Valid Until:
CONTRACT  Office  Warehouse  N/A
8. FORECAST FOR
FORTHCOMING YEAR 18. LATEST SEMI-ANNUAL
 Importer  Manufacturer  N/A Dated received:
(for manufacturing &/or REPORT SUBMITTED
manufacturers only)

9. MSDS/ SDS OF 19a: P License No.:

CONTROLLED  Submitted  N/A 19. LATEST P-LICENSE ISSUED
SUBSTANCES HANDLED 19b: Validity:

I hereby attest and certify that the information provided on this application from are true and correct based on personal knowledge and supporting documents are AUTHENTIC
records. It is understood t h a t the Entity and its responsible signatory are bound to comply with the pertinent provisions of R.A. 9165, as well as relevant regulations
promulgated by the Dangerous Drugs Board (DDB). Lastly, we hereby bound ourselves together with the entity to be criminally liable for violation of the provision of the
revised penal code for non-compliance of the above requirements.
________________________________________________________________________ ___________________________________________________________________________
Printed Name and Signature of Head of Office Printed Name, Signature of Authorized Pharmacist/Signatory
 CLIENT’S DATA PRIVACY CONSENT FORM

PDEA Compliance Service adheres and complies with the Data Privacy Act of 2012 (RA No. 10173) and its Implementing
Rules and Regulations (IRR) to safeguard Client’s Data Privacy Rights.
The herein named Client, by signing this Consent Form, it is construed that in his / her application for S2 License / S License / P
License / Accreditation as Transporter / Import/ Export Permit/ Special Permit and other transactions; has agreed and consented to
the following:
 Allow PDEA Compliance Service and its authorized representatives to collect, use, process and share pertinent Data
collected with other Government regulatory agencies the following information;
for S2 license – Name/Home and Office/Clinic Address/Contact No./Email/Birthdate/PRC ID/Drug Test
Result/signature.
for S/P license and Accreditation – Name/Home and Office Address/Email/Contact No./PRC ID/Business permit/SEC
Registration/FDA LTO/BOC Accreditation/signature.
 Allow PDEA Compliance Service to use/ share relevant Data for statistical research, and other lawful purposes;
 All Records and relevant data collected will be stored/ disposed of in a manner in accordance with applicable laws and
policies of the National Archives of the Philippines (NAP).

Conforme:

_______________________________________
Name and Signature of Signatory

_______________________________________
Company/ Position

______________________________________
Date Signed