FM-CSVlrd-01 (page 1 of 2)
PHILIPPINE DRUG ENFORCEMENT AGENCY
Compliance Service Room 213, PDEA Bldg., NIA Northside Road, Bgy. Pinyahan, Q.C.1100
Tel. No: 927-9702 loc. 197, 198 / Telefax: 920-8110
Email: cs@pdea.gov.ph / Website: pdea.gov.ph
S2 APPLICATION FORM FOR REGISTRATION OF MEDICAL PRACTITIONERS
(Physician / Dentist / Veterinarian) Rev_4_August 1, 2017
ONLY DULY FILLED-OUT AND SIGNED FORM WITH COMPLETE REQUIREMENTS WILL BE PROCESSED
Date:
MARK APPROPRIATELY BOXES WITH √ NEW RENEWAL LOST
FOR RENEWAL APPLICANTS THRU A REPRESENTATIVE, PLEASE FILL-OUT AND SIGN AUTHORIZATION LETTER AT THE BACK HEREOF.
SURNAME
NAME
FIRST NAME EXTENSION
(e.g. Jr., Sr.)
MIDDLE NAME
MOTHER'S MAIDEN NAME
Preferred Login Name
(NMT 10 characters) EMAIL ADDRESS
DATE OF BIRTH MOBILE NO.
(mm / dd / yyyy)
RESIDENTIAL
SEX Male Female ADDRESS
Single Widowed
CIVIL STATUS Married Separated ZIPCODE
Annulled Others, TEL. NO.
TEL. NO. FAX NO.
HOSPITAL / CLINIC
PROFESSION Physician
Veterinarian ADDRESS
Dentist
ZIPCODE
SECTOR Government Private TEL. NO. FAX NO.
PRESENT ORIGINAL DOCUMENTS FOR VALIDATION AND SUBMIT CLEAR PHOTOCOPY
S2 ID CARD / CERTIFICATE 1a TIN ID CARD / LATEST ITR / BIR TIN 4a
1a. S2 License No. 4 VERIFICATION SLIP / e -TIN
1b. Date Issued 4a. TIN (one time submission)
1b 4b
1c. Valid Until 4b. Date Issued
1 FOR LOST OF VALID
1c DRUG TEST - DOH-DDB IDTOMIS 5a 5a
S2 ID CARD /
GENERATED REPORT
CERTIFICATE : Submit
AFFIDAVIT OF LOSS AND 5b
5a. Drug Test Result
POLICE BLOTTER
PRC ID CARD 2a 5b. Date Issued 5c
2a. PRC License #
2b. Date Issued 2b 5c. Name of DOH Accredited Drug Testing
2 2c. Validity
5 Center
Note: Validity of S2 License 2c 5d
5d. Address
is harmonized with the PRC
ID Card Validity
PTR 3a 1 pc 2" x 2" ID picture with
3a. PTR O.R. # white background taken not
3b
6 later than 6 months from
3b. Date Issued
3 application, without eyeglasses
ID PICTURE
2X2
FOR GOVERNMENT MEDICAL PRACTITIONERS: Submit CERTIFICATE OF EMPLOYMENT in lieu of PTR
and original NOTARIZED AFFIDAVIT attesting that S2 license shall be used exclusively for government
practice only. Government practitioners are exempted from registration fee.
I SOLEMNLY SWEAR that the statements made on this Application Form are true and the attached supporting documents are authentic. It is
understood that I am bound to comply with the provision of RA 9165, otherwise known as the, “Comprehensive Dangerous Drugs Act of 2002,” and
other pertinent rules and regulations implemented by the Philippine Drug Enforcement Agency.
__________________________________
Printed Name and Signature of Applicant
PROCESSED BY: APPROVED BY:
________________________________________________ DIR. III HELEN MAITA E. REYES, RPh, MBA,MGM
Signature Over Printed Name DIRECTOR, COMPLIANCE SERVICE
FM-CSVlrd-01 (page 2 of 2)
AUTHORIZATION
Date :
Director General
Philippine Drug Enforcement Agency
NIA Northside Road, National Government Center,
Brgy. Pinyahan, Quezon City
Attention: DIR III HELEN MAITA E. REYES, RPh, MBA, MGM
Director, Compliance Service
Dear Sir/Ma’am,
I hereby authorize the bearer whose signature and/or right thumb
mark appear below, to apply for and in my behalf:
[ ] S2 license renewal / [ ] S2 license re-application due to lost S2
for the period covering date of expiration / lost of my S2 license until (expiry of
current PRC license), for which I have filled-out the application at the reverse side.
____________________________________ ____________________________________
Signature of Authorized Representative Signature of Applicant
___________________________________ ____________________________________
Printed Name of Authorized Representative Printed Name of Applicant
Right thumb mark
of representative
REMINDERS
NEW APPLICANT IS REQUIRED TO APPLY IN PERSON AT THE PDEA COMPLIANCE SERVICE / REGIONAL
COMPLIANCE SECTION.
UNLESS SURRENDERED, SUSPENDED OR REVOKED LICENSE SHALL BE RENEWED ON OR BEFORE
EXPIRATION DATE AFTER RENEWAL OF LICENSE FROM PRC. BRING ORIGINAL AND PHOTOCOPY OF
OFFICIAL RECEIPT (O.R.) AND CLAIM SLIP.
A SURCHARGE OF PHP 500.00 PER YEAR WILL BE IMPOSED FOR NON-RENEWAL OF LICENSE.
NOTIFY PDEA IN WRITING AT LEAST 60 DAYS IN ADVANCE FOR AN INTENTION TO DISCONTINUE/RETIRE
THE S2 LICENSE AUTHORITY GRANTED.
WRITTEN NOTIFICATION ON LOSS OF LICENSE WITHIN 48 HOURS FROM OCCURRENCE TO PDEA
COMPLIANCE SERVICE/REGIONAL COMPLIANCE SECTION. ADDITIONALLY SUBMIT NOTARIZED AFFIDAVIT
OF LOSS AND POLICE BLOTTER.
RE-APPLICATION FOR A NEW LICENSE AND PAYMENT OF CORRESPONDING FEES.
A DANGEROUS DRUG PREPARATION IS PRESCRIBED IN A SPECIAL PRESCRIPTION FORM FOR DANGEROUS
DRUGS WITH S2 LICENSE INDICATED THEREIN UNLESS OTHERWISE EXEMPTED BY A REGULATION.
