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PAICS COPY

Bureau of Food and Drugs Policy, Planning, and Advocacy Division A S S E S S M E N T S L I P FOOD
DATE: October 21, 2013 RSN:

ACCOUNTING SECTIONS COPY

Annex

E
Bureau of Food and Drugs Policy, Planning, and Advocacy Division A S S E S S M E N T S L I P FOOD
DATE: October 21, 2013 RSN:

Applicant Company Address/Tel no. LTO No./Validity

: __HACIENDA MACALAUAN, INC.____________________________ : ___BRGY. MABACAN, CALAUAN, LAGUNA__________________ : __RDII RIV F 2275__________________________________ Importer Exporter Wholesaler

Applicant Company Address/Tel no. LTO No./Validity

: __HACIENDA MACALAUAN, INC.____________________________ : ___BRGY. MABACAN, CALAUAN, LAGUNA__________________ : __RDII RIV F 2275__________________________________ Importer Exporter Wholesaler

Manufacturer Distributor/Wholesaler PRODUCT INFORMATION


Brand name and Product Name Product Classification (Category/Code) List of Products Number of Products Applied Packaging Types and Sizes Registration Number (FR) Applicant Company Manufacturer Repacker Distributor Others (Pls. specify) Number of Samples : : : : : : : : : :

Manufacturer Distributor/Wholesaler PRODUCT INFORMATION


Brand name and Product Name Product Classification (Category/Code) List of Products Number of Products Applied : : : : : : : : : :

PURE AND BEST LACTOSE FREE WHOLE MILK CAT 1

PURE AND BEST LACTOSE FREE WHOLE MILK CAT 1

1 liter and 200ml Validity: ___________________________________ HACIENDA MACALAUAN, INC. HACIENDA MACALAUAN, INC.

Packaging Types and Sizes Registration Number (FR) Applicant Company Manufacturer Repacker Distributor Others (Pls. specify) Loose Labels:_______________________________ Number of Samples

1 liter and 200ml Validity: __________________________________ HACIENDA MACALAUAN, INC. HACIENDA MACALAUAN, INC.

: __________________

: __________________

: ___1______________

: __1_______________

Loose Labels:_______________________________

APPLICATION DETAILS Application Type


Initial Renewal Renewal with Surcharge Re-application (OLD RSN:_______________) No. of CPR Validity Applied for (year/s)

APPLICATION DETAILS Category I Category II Food Supplement Bottled Water Application Type
Initial Renewal Renewal with Surcharge Re-application (OLD RSN:_______________) No. of CPR Validity Applied for (year/s)

Category I

Category II

Food Supplement

Bottled Water

OTHER REQUESTS
Amendment of CPR Re-issuance/Reconstruction of CPR Referral to ACB

OTHER REQUESTS
Provisional Permit to Market (PPM) Export Certificate Others, pls. specify

Amendment of CPR Re-issuance/Reconstruction of CPR Referral to ACB

Provisional Permit to Market (PPM) Export Certificate Others, pls. specify

PAYMENT DETAILS
EVALUATOR Fee Surcharge TOTAL Evaluated by : : : : JOANNA MARIES NARVAEZ CASHIER Amount OR Number Date Issued Received by : : : :

PAYMENT DETAILS
EVALUATOR Fee Surcharge TOTAL Evaluated by : : : : JOANNA MARIES NARVAEZ CASHIER Amount OR Number Date Issued Received by : : : :

RECEIPT DETAILS
Name Signature
KJFSLFJASKFJALDFJLAFJLSKDJFLAKSJDFLJASKDFJALSD

RECEIPT DETAILS
: : Name Signature
KJFSLFJASKFJALDFJLAFJLSKDJFLAKSJDFLJASKDFJALSD

: :