Republic of the Philippines ANNEX A Department of Health HEALTH FACILITIES AND SERVICES REGULATORY BUREAU REGISTRATION OF PATIENT TRANSPORT VEHICLE (PTV) Owner ofVehicle: MUNICIPALITY OF MANOLO FORTICH. (@8 reflected in the Land Transportation Office (LTO) Registration) Complete Address: __CALANAW, TANKULAN No. & Street Barangay MANOLO FORTICH BUKIDNON 10 Region City/ Municipality Province Tel. /Fax.No.: (088) 228-2437 Mobile No.:.09177293517 E-mail Address: mhomanolofortich@amail.com so |. Classification: A. According to Institutional Character: Institution-Based: PTVs owned by Health Facilities regulated by the Department of Health (DOH), tick ( appropriate box: 0 Hospital O General : 0 Level 1 0 Level 2 0 Level 3 0 Specialty, please specify 0 Infirmary Birthing Home O Others, please specify Non-Institution-Based/ Free-Standing: PTVs not owned by Health Facilities regulated by the DOH , tick( appropriate box. 0 Provincial Health Office 0 Rural Health Unit ‘Municipal Health Office Barangay Health Station City Health Office O Health Center 0 Others, please specify B. According to Ownership. V Government 0 Private No. of Vehicles for Registration: 1 Listdown the LTO Certificate of Registration and Plate Number or Conduction Sticker Number per vehicle applied for registration: Vehicle | LTO Certificate of Registration Piate ere oe 1 207741413 URI335° z 3 [romerven | | mec | otezie LRemieleAcknowledgement REPUBLIC OF THE PHILIPPINES ) CITY/ MUNICIPALITY OF MANOLO FORTICH) SS. |, __JOANNE MARIE V.DUENAS _ MARRIED 38 YEARS OLD, of legal age, FEMALE , aresident Name iil Status Age of TANKULAN MANOLO FORTICH. , after having been sworn in accordance with Address. law hereby depose and say that | am executing this affidavit to attest to the completeness and truth of the foregoing information for the Registration of Patient Transport Vehicles in the Philippines pursuant to Administrative Order No. 2018-0001 “Revised Rules and Regulations Governing the Licensure of Land Ambulances and Ambulance Service Providers.” signature Before me, this 15TH day of JANUARY 2020 __in the City/Municipality of MANOLO FORTICH ___, Philippines, personally appeared the above affiant with Community Tax Certificate No, 16429516. issued on JANUARY 14, 2020 at MANOLO FORTICH __, known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is their free act and deed. IN WITNESS WHEREOF, | have hereunto set JANUARY, 2020. tov Doc. No. bapa! C ”ARVPUBLIC CF Page No. “ My Commission Book No. Expires Series of Dec. 31, For PTR | Reno Sufetore Page: off