Professional Documents
Culture Documents
Rm 213 (Compliance Service), PDEA Building, NIA Northside Road, Bgy. Pinyahan, Q.C. 1100
Tel. No. 927-9702 loc. 198, 197 / Telefax 920-8110
Email: pdea_cs@yahoo.com.ph / Website: pdea.gov.ph
APPLICATION SHEET (S2- LICENSE)
APPLICATION FOR REGISTRATION TO PRESCRIBE DANGEROUS DRUG PREPARATIONS
&/OR DRUG PREPARATIONS CONTAINING TABLE 1 CONTROLLED CHEMICALS
AS PRACTITIONERS (Physician / Dentist / Veterinarian)
Form: S2LA-2009
ONLY DULY- FILLED OUT AND SIGNED FORM WITH COMPLETE REQUIREMENTS WILL BE PROCESSED
Date
Paper ID
MARK APPROPRIATE BOXES WITH
NEW
LOST ID
RENEWAL
FOR RENEWAL APPLICANTS, PLEASE FILL OUT AND SIGN AUTHORIZATION LETTER AT THE BACK HEREOF.
PVC ID
SURNAME
NAME EXTENSION
(e.g. Jr., Sr.)
FIRST NAME
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
CIVIL STATUS
Single
Married
Annulled
Widowed
Separated
Others,
ZIPCODE
TEL. NO.
HOSPITAL
Physician
Veterinarian
Dentist
PROFESSION
FAX NO.
ADDRESS
ZIPCODE
SECTOR
TEL. NO.
FAX NO.
Government Private
REQUIREMENTS (SUBMIT CLEAR DULY-CERTIFIED TRUE COPY. PRESENT ORIGINAL COPY FOR VALIDATION):
FOR
RENEWAL
ONLY
1b
1c
PTR
3a. PTR O.R. #
3b. Date Issued
4a
4b
5a
2c
2c. Validity
1a
NEGATIVE
5b
5c
5d
3a
3b
FOR GOVERNMENT PHYSICIANS: Submit latest 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 attach
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.
RECOMMEND APPROVAL:
AUTHORIZATION
_________________
Date
Sir/Madam:
I hereby authorize the bearer _________________________________ whose signature and right thumb mark
appear below, to apply for and in my behalf:
[
] S2 license renewal
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