Professional Documents
Culture Documents
Department of Health
REGIONAL OFFICE III
APPLICATION FOR LICENSE TO OPERATE
Name of Health Facility :
Address :
No. & Street Barangay
Owner :
Classification According to:
Ownership : [ ] Government [ ] Private
Institutional Character: [ ] Hospital based [ ] Non-hospital based
Note: Please refer to www.bhfs.doh.gov.ph. Application Form for other ancillary services
Form-HF-LTO-A
Revision: 00
Name and Signature of Applicant Date of Application 06/06/2013
Page 1 of 5
ANNEX A
LIST OF PERSONNEL
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
STATUS
DEPARTMENT PRC No.
Permanent
Temporary
NAME POSITION SIGNATURE
Others,
(if hospital)
specify
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
DATE CONDITION
ITEM QTY REMARKS
ACQUIRED New Serviceable
Form-HF-LTO-A
Revision:00
06/06/2013
Page 4 of 5
Acknowledgement
REPUBLIC OF THE PHILIPPINES ) CITY/
MUNICIPALITY OF ) S.S.
Signature
known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me
IN WITNESS WHEREOF, I have hereunto set my hands this ____day of ________________, 20___
Form-HF-LTO-A
Revision:00
06/06/2013
Page 5 of 5