Republic of the Philippines

Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Manila

APPLICATION FOR RENEWAL OF LICENSE

To Establish, Operate and Maintain an HIV Testing Laboratory

The Director
Bureau of Health Facilities and Services

Dear Sir:

I have the honor to apply for renewal of license to operate the :

Name of HIV Testing Laboratory _________________________________________________________

Category / Classification _________________________ Date first operated _______________________
Accreditation No. __________________ Issued on _________________________________, 20 _______
Name of Owner _______________________________________________________________________
Address ______________________________________________________________________________
Name of Head ________________________________________________________________________
Address ______________________________________________________________________________

The personnel are :

Name Address Position Educational Attainment /
Board Registry No.
____________________ ________________________ ___________________ ________________________
____________________ ________________________ ___________________ ________________________
____________________ ________________________ ___________________ ________________________
____________________ ________________________ ___________________ ________________________

I bind myself to see that the operation of the HIV Testing Laboratory is in accordance with the Rules and
Regulations issued to implement R.A. 4688 (Clinical Laboratory Law).

Please acknowledge receipt of enclosed renewal fee of P _____________.

Very truly yours,

_____________________________
Name in print and signature

_____________________________
Designation

SUBSCRIBED AND SWORN to before me this _______ day of _______________________20 _____ at

___________________________. Affiant exhibited to me his Residence Tax Certificate No. ________ issued at
____________________ on __________, 20 ____.

Doc. No. _______________________

Page No. _______________________ _____________________________________
Notarial Reg. No. ________________ Notary Public
Series of _______________________
Documentary Stamps P 3.00 My Commission expires on Dec. 31, 20 ____.
 TESTING MATERIALS

SCREENING TEST(S), specify name of kit:

____ EIA LOT #

_______________________________ __________________________________
_______________________________ __________________________________
_______________________________ __________________________________

____ PA LOT #

_______________________________ __________________________________
_______________________________ __________________________________
_______________________________ __________________________________

SUPPLEMENTAL TEST(S), specify name of kit:

____ WB LOT #

_______________________________ __________________________________
_______________________________ __________________________________
_______________________________ __________________________________

____ IF LOT #

_______________________________ __________________________________
_______________________________ __________________________________
_______________________________ __________________________________

____ OTHERS LOT #

_______________________________ __________________________________
_______________________________ __________________________________
_______________________________ __________________________________