APPLICATION SHEET FOR ACCREDITATION

truck depot address zip code e-mail address tel no. fax no. entity’s representative information name of head/ owner/operator designation home address ...

0 downloads 21 Views 705KB Size
`

Republic of the Philippine Office of the President

FM-CSVlrd-04 (page 1 of 2)

PHILIPPINE DRUG ENFORCEMENT AGENCY COMPLIANCE SERVICE PDEA Bldg. NIA Northside Road, National Government Center, Barangay Pinyahan, Quezon City 1100 | Email: [email protected] / www.pdea.gov.ph | (02) 927-9702 loc. 197/198 / 920-8110

APPLICATION SHEET FOR ACCREDITATION (As Transporter/Hauler/Carrier of Bulk Controlled Substances) MARK APPROPRIATELY BOXES  WITH √

    RENEWAL

NEW

Rev_0_April 30, 2018

DATE:

FILL-OUT BLANKS. TYPE OR PRINT LEGIBLY. ONLY SIGNED FORMS WITH COMPLETE DOCUMENTS/ REQUIREMENTS WILL BE PROCESSED. FOR NEW APPLICANTS: ONLY THE HEAD OR AUTHORIZED PHARMACIST/SIGNATORY SHALL BE ALLOWED TO TRANSACT BUSINESS WITH PDEA. FOR RENEWAL APPLICANTS THRU A REPRESENTATATIVE, PLEASE FILL-OUT AND SIGN AUTHORIZATION LETTER AT THE BACK HEREOF.

PRESENT ORIGINAL DOCUMENTS FOR VALIDATION AND SUBMIT CLEAR PHOTOCOPY NAME OF ENTITY BUSINESS ADDRESS

ZIP CODE

TRUCK DEPOT ADDRESS

ZIP CODE

E-MAIL ADDRESS

TEL NO.

FAX NO.

ENTITY’S REPRESENTATIVE INFORMATION NAME OF HEAD/ OWNER/OPERATOR DESIGNATION HOME ADDRESS E-MAIL ADDRESS TEL./MOBILE NO. NATIONALITY NBI CLEARANCE

Findings:

Date Issued:

ENTITY’S INFORMATION 1. MAYOR’S PERMIT 1a. MP No. 1b. Official Receipt No. 1c. Date Issued / Valid Until

1a. 1b. 1c.

7. DOST CALIBRATION CERTIFICATE/TEST REPORT (When applicable) 7a. Cert No. 7b. Date Issued 7c. Valid Until 8. NOTARIZED AFFIDAVIT OF UNDERTAKING SWORNED ON

7a.

9. With names, positions and pictures of officers (one-time submission)  10. (one-time submission)  11.( (one-time submission)  Office  Warehouse 12.(Front view with signage (one-time submission)  Office  Warehouse 13. (one-time submission)  Office  Warehouse 14. (one-time submission)

2. DTI/SEC/CDA CERTIFICATE 2a. Registration No. 2b. Validity

2a.

3. Current GIS (For corporations only) Dated

3.

9.ORGANIZATIONAL STRUCTURE (Duly Authenticated)

4. TIN CARD/ ITR 4a. TIN 4b. Date Issued (one-time submission) 5. CONTRACT OF AGREEMENT (Between Transporter/ Hauler/Carrier & Client) 5a. Date Issued 5b. Valid Until 6. DESCRIPTION AND SPECIFICATION OF VEHICLES 6a. Photographs of front, back, and side view 6b. Proof of ownership of the vehicle (Certificate of Registration and Official Receipt) 6c. LTO Registration No. 6d. Contract of lease and /or Deed/s of Sale of the vehicle (if applicable)

4a. 4b.

10. ENTITY’S PROFILE (Duly authenticated) 11. LOCATION/ VICINITY MAP

5a.

12.PICTURE OF ESTABLISHMENT

5b.

13. PROOF OF OWNERSHIP/ LEASE CONTRACT 14. PROVISION FOR A GARAGE (Include sketch map and photographs)

2b.

6a. (one-time submission) 

7b. 7c. 8.

 6b. (one-time submission) 

15. Name of Driver/s 15a. Professional Driver’s License

15a. (one-time submission) 

6c. 

6d. (one-time submission) 

I SOLEMNLY SWEAR that the statements made on this Application Form are true and the attached supporting documents are authentic. It is understood that the Trucking Company and its responsible signatory officer is bound to comply with the provisions of R.A. 9165, Board Regulation No. 1. Series 2014and other pertinent regulations implemented by the Philippine Drug Enforcement Agency. _____________________________________________ Printed Name and Signature of Head/Owner/Operator

Approved by: ___________________________________________

FM-CSVlrd-04 (page 2 of 2)

AUTHORIZATION Date : Director General Philippine Drug Enforcement Agency NIA Northside Road, National Government Center, Brgy. Pinyahan, Quezon City Attention: Director, Compliance Service

Dear Ma’am/Sir, I hereby authorize the bearer

whose signature appears below to:

________:

file renewal application with requirements

________:

claim/pick-up License to Handle (LTH)

( N A M E )

in my behalf. I shall be accountable for any violation/s that might be committed for the said transaction. ___________________________________________________ Printed Name and Signature of Authorized Signatory/pharmacist ______________________________________________ Printed Name and Signature of Authorized Representative (To present/submit original/photocopy of valid Company ID)

REMINDERS    

UNLESS SURRENDERED, SUSPENDED OR REVOKED SUCH SHALL BE RENEWED. MAY RENEW THREE (3) MONTHS PRIOR TO EXPIRATION. A SURCHARGE OF 50% OF THE REQUIRED ANNUAL FEE, CUMULATIVELY BY YEAR NOT PAID SHALL BE IMPOSED ON TOP OF THE CURRENT ANNUAL FEE. NOTIFY PDEA IN WRITING AT LEAST 60 DAYS IN ADVANCE FOR AN INTENTION TO DISCONTINUE/RETIRE THE ACCREDITATION GRANTED. WRITTEN NOTIFICATION IN CASES OF LOSS, THEFT, PILFERAGE AND OTHER ANALOGOUS CIRCUMSTANCES DURING TRANPORT OF CONTROLLED SUBSTANCE WITHIN 48 HOURS FROM OCCURRENCE TO PDEA COMPLIANCE SERVICE/REGIONAL COMPLIANCE SECTION, ADDITIONALLY SUBMIT NOTARIZED AFFIDAVIT OF LOSS AND POLICE BLOTTER.