lOMoARcPSD|52801361
FM-CSVlrd-02 S License Rev 4 May 8 2023 09May2023
Professional Ethics, Jurisprudence and Cultural Sensitivity (Our Lady of Fatima
University)
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lOMoARcPSD|52801361
Republic of the Philippines FM-CSVlrd-02_Rev_4_May 8, 2023
Office of the President
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 pdeatopstories
S-LICENSE APPLICATION FORM
(License to handle Dangerous Drugs/ Dangerous Drug Preparation/s /
Table I Controlled Chemical/s used in the manufacture of drug preparation)
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.
S- LICENSE APPLIED FOR S1 S3 S4 S5C S5D S5-E S5-I S6
NAME OF ENTITY
NATURE OF
SECTOR Government
Private
BUSINESS
OFFICE / BUSINESS ADDRESS ZIP CODE
WAREHOUSE / PLANT
ZIP CODE
ADDRESS
OFFICIAL E-MAIL ADDRESS TEL. NO. FAX NO.
ENTITY’S REPRESENTATIVE INFORMATION
NAME OF HEAD OF NAME OF AUTHORIZED
OFFICE PHARMACIST / SIGNATORY
DESIGNATION DESIGNATION
RESIDENTIAL ADDRESS RESIDENTIAL ADDRESS
E-MAIL ADDRESS E-MAIL ADDRESS
MOBILE / CELLPHONE NO. MOBILE / CELLPHONE NO.
NATIONALITY NATIONALITY
1. NBI CLEARANCE 1a. Findings: 3. NBI CLEARANCE 3a. Findings:
(one-time submission) 1b. Validity: (one-time submission) 3b. Validity:
4a. Registration No.:
2. NOTARIZED JOINT DATE NOTARIZED: 4. PRC ID CARD 4b. Registration Date:
AFFIDAVIT
4c. Valid until:
ENTITY’S INFORMATION
5. DTI / SEC / CDA Certificate 10. CERTIFICATE OF PRODUCT 10a. CPR
& Articles of Inc. 5a. Registration No.: Submitted N/A
REGISTRATION (CPR) /
(one-time submission
PICTURE/S OF DDP/S 10b. Picture of DDPs
depending on validity)
5b. Registration Date: Box Label Picture
Package submission)
Insert
6. Current GIS (for 11. ENTITY’S PROFILE 11. (one-time
corporations only) 6. Dated:
(BRIEF & CONCISE) Submitted N/A
Office: 12. LOCATION / VICINITY MAP 12. (one-time submission)
7a1. Permit No.: Office Warehouse N/A
7a2. Date Issued:
7a3. Valid Until:
7a4. Official Receipt No.: 13. PICTURE OF ESTABLISHMENT 13. (one-time submission)
7a5. Date Issued (Front View with signage) Submitted N/A
7. MAYOR’S PERMIT
Warehouse/ Plant:
7b1. Permit No.: 14. FLOOR PLAN/LAY-OUT TO 14. (one-time submission)
7b2. Date Issued: HIGHLIGHT STORAGE AREA Office Warehouse N/A
7b3. Valid Until:
7b4. Official Receipt No.: 15. PICTURE OF CONTROLLED 15. (one-time submission)
7b5. Date Issued SUBSTANCE’S STORAGE AREA Office Warehouse N/A
(showing double locks & with
8a. License No.: Dimension )
8. DOH / FDA LTO 8b Official Receipt No.: 16. PROOF OF OWNERSHIP / LEASE
16. (one-time submission)
CONTRACT
Office Warehouse N/A
8c Date Issued/ Valid Until:
9. BOC ACCREDITATION 9a BOC No.: N/A 17. LATEST SEMI-ANNUAL
CERTIFICATE REPORT SUBMITTED Date received:
9b Date issued: (For renewal applicants only)
(For importers / exporters
only) 18. LATEST S-LICENSE ISSUED 18a: S License No.:
9c Valid Until:
(For renewal applicants only) 18b: Validity:
I hereby attest and certify that the information provided on this application form 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 and Signature of Authorized Pharmacist/Signatory
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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 Application – Name/Home and Office/Clinic Address/Contact No./Email/Birthdate/PRC ID/Drug Test
Result/signature.
for S/P license /Accreditation Application – 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 Applicant Date Signed
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