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Application For License To Operate: Health Facilities and Services Regulatory Bureau
Application For License To Operate: Health Facilities and Services Regulatory Bureau
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
Owner :
Note: Please refer to www.hfsrb.doh.gov.ph Application Form for other ancillary services
Form-HF-LTO-A
Name and Signature of Applicant Date of Application Revision:03
08/02/2016
Page 1 of 5
ANNEX A
LIST OF PERSONNEL
Address :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
Highest
Educational Specialty Board
Designation/ Attainment and Certificate (for
Name PRC STATUS
Position Post Graduate physicians), specify Signature
Course (if (where applicable)
applicable)
Contractual
Permanent
Validity Others,
Reg. No.
Period specify*
Form-HF-LTO-A
Prepared by: ___________________________________________ Revision:03
08/02/2016
Page 2 of 5
ANNEX B
LIST OF EQUIPMENT/INSTRUMENT
Address :
Form-HF-LTO-A
Revision:03
08/02/2016
Page 3 of 5
ANNEX C
LIST OF SERVICES IN A HOSPITAL
Form-HF-LTO-A
Revision:03
08/02/2016
Page 4 of 5
Acknowledgement
REPUBLIC OF THE PHILIPPINES )
CITY/ MUNICIPALITY OF )
S.S.
Signature
known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me
Form-HF-LTO-A
Revision:03
08/02/2016
Page 5 of 5