PAICS COPY ACCOUNTING SECTION’S COPY Annex E

Bureau of Food and Drugs Bureau of Food and Drugs

Policy, Planning, and Advocacy Division Policy, Planning, and Advocacy Division
A S S E S S M E N T S L I P A S S E S S M E N T S L I P
FOOD FOOD

DATE: RSN: DATE: RSN:

Applicant Company : _______________________________________________________ Applicant Company : _______________________________________________________

Address/Tel no. : _______________________________________________________ Address/Tel no. : _______________________________________________________
LTO No./Validity : _______________________________________________________ LTO No./Validity : _______________________________________________________

 Manufacturer  Distributor/Wholesaler  Importer  Exporter  Wholesaler  Manufacturer  Distributor/Wholesaler  Importer  Exporter  Wholesaler
PRODUCT INFORMATION PRODUCT INFORMATION
Brand name and Product Brand name and Product
Name : Name :
Product Classification Product Classification
(Category/Code) : (Category/Code) :

List of Products : List of Products :

Number of Products Applied : Number of Products Applied :

Packaging Types and Sizes : Packaging Types and Sizes :

Registration Number (FR) : __________________ Validity: ___________________________________ Registration Number (FR) : __________________ Validity: __________________________________

Applicant Company : Applicant Company :

Manufacturer : Manufacturer :

Repacker : Repacker :

Distributor : Distributor :

Others (Pls. specify) : Others (Pls. specify) :

Number of Samples : __________________ Loose Labels:_______________________________ Number of Samples : __________________ Loose Labels:_______________________________
APPLICATION DETAILS APPLICATION DETAILS
Category Category Food Bottled Category Category Food Bottled
Application Type Application Type
I II Supplement Water I II Supplement Water
Initial     Initial    
Renewal     Renewal    
Renewal with Surcharge     Renewal with Surcharge    
Re-application (OLD RSN:_______________)     Re-application (OLD RSN:_______________)    
No. of CPR Validity Applied for (year/s) No. of CPR Validity Applied for (year/s)
OTHER REQUESTS OTHER REQUESTS
 Amendment of CPR  Provisional Permit to Market (PPM)  Amendment of CPR  Provisional Permit to Market (PPM)
 Re-issuance/Reconstruction of CPR  Export Certificate  Re-issuance/Reconstruction of CPR  Export Certificate
 Referral to ACB  Others, pls. specify  Referral to ACB  Others, pls. specify

PAYMENT DETAILS PAYMENT DETAILS

EVALUATOR CASHIER EVALUATOR CASHIER
Fee : Amount : Fee : Amount :
Surcharge : OR Number : Surcharge : OR Number :
TOTAL : Date Issued : TOTAL : Date Issued :
Evaluated by : Received by : Evaluated by : Received by :
RECEIPT DETAILS RECEIPT DETAILS
Name : Name :
Signature : Signature :
KJFSLFJASKFJALDFJLAFJLSKDJFLAKSJDFLJASKDFJALSD
KJFSLFJASKFJALDFJLAFJLSKDJFLAKSJDFLJASKDFJALSD
PAICS COPY ACCOUNTING SECTION’S COPY Annex E