Dealership Application - R - Fertilizer and Pesticide Authority

REPUBLIC OF THE PHILIPPINESDEPARTMENT OF AGRICULTUREFERTILIZER AND PESTICIDE AUTHORITYFPA Building, BAI Compound Visayas Ave., Diliman, Quezon CityTel. Nos. 922 - 3368 / 927 - 3647 / 441 - 1601 / 920 - 8573 / 920 - 0068 / 920 - 8173Telefax. 920 - 8573E-mail Address: fpa_77@yahoo.comAPPLICATION FOR DEALERSHIP LICENSEWebsite: http://fpa.da.go.phNOT FOR SALE_______ Fertilizer_______ Pesticide_______ Household_______ Wood Preservative______ Both Fertilizer & Pesticide______ Other Agrc’l. ChemicalsPLEASE READ INSTRUCTION. Answer all questions completely. Be sure to write additional commentsas requested. This license will be automatically revoked if you are found in possession of or sellingunregistered products or products obtained from unlicensed sources.1. Business Name: __________________________________________________________________________Telephone No.: __________________2. Business Address:a.) Main _______________________________________________________________________________(Barrio) (Town) (Province)b,) Branch/es: __________________________________________________________________________(Barrio) (Town) (Province)3. Name of Owner: _________________________________________________________________________(Family) (First) (Middle)Sex: ________ Civil Status: ____________ Age: _____________4. Name of Authorized Representative: ________________________________________________________5. Type of Ownership:________ Single proprietorship________ Partnership________ Corporation________ Cooperative6. Capitalization: P _____________7. Name of Personnel who attended Agro-dealers/ retailers training:NameDate & Placeof TrainingRating8. List of Fertilizer and Pesticide Products:9. List of Outlets (Business Name & Address: )