Anda di halaman 1dari 2

PHILIPPINE DRUG ENFORCEMENT AGENCY

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):

1b. Date Issued


1c. Valid Until

FOR
RENEWAL
ONLY

S2 ID CARD (original for surrender)


1a. S2 License #

1b

1c

FOR LOST ID: Submit proof of publication of loss


PRC ID CARD
2a
2a. PRC License #
2b
2b. Date Issued

PTR
3a. PTR O.R. #
3b. Date Issued

TIN ID CARD / LATEST ITR


4a. TIN
4b. Date Issued
DRUG TEST

4a
4b
5a

5a. Drug Test Result


5b. Date Issued
5c. Name of Accredited
Drug Testing Center
5d. Drug Testing Center
Address

2c

2c. Validity

1a

NEGATIVE

5b
5c

5d

3a
3b

6 1 pc 2" x 2" ID picture with white


background

taken not later than 6 months from application,


wearing of eyeglasses not allowed

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:

Director, Compliance Service

Printed Name and Signature of Applicant


Note: Expiration of S2 license is adjusted to coincide with the PRC ID Card validity.
S2 LICENSE Paid Under
Official Receipt Number :
Date:
Amount:

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

] 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