Republi ofthe Pipe (Oso he Peet PHILIPPINE DRUG ENFORCEMENT AGENCY COMPLIANCE SERVICE PDEA Bldg, NIA Noth Rood, National Government Center, Bazangey Finale, Quezon Cy 1100 | Em pd gon ph / ww pen gov ph | 2) 7703 oT 18 / 0-870 S-LICENSE APPLICATION FORM FOR NON-PRACTITIONER'S (Handling Dangerous Drugs! Dangerous Drug Preparationis /Table I Controlled Chemicalls usedin the manufacture of drug preparation) FM-CSVird-02 (page 1 of 2) Rev_0_April 30, 2018 ‘MARK APPROPRIATELY BOXES WITH 7 O_ NEW RENEWAL DATE: FILL-OUT BLANKS. TYPE OR PRINT LEGIBLY. ONLY FORMS WITH COMPLETE DOCUMENTS’ REC WILL BE PROCESSED. ‘FOR NEW APPLICANTS: ONLY THE HEAD OR AUTHORIZED PHARMACISTISIGNATORY SHALL BE ALLOWED TO TRANSACT BUSINESS WITH PDEA. ‘FOR RENEWAL APPLICANTS THRU A REPRESENTATIVE, PLEASE FILL-OUT AND SIGN AUTHORIZATION LETTER AT THE BACK HEREOF. PRESENT ORIGINAL DOCUMENTS FOR VALIDATION AND SUBMIT CLEAR PHOTOCOPY LUGENSEAPPLEDFOR | Cst ass asa asse asso asse Ossi ass SIreUSeENT DR. PABLO O. TORRE MEMORIAL HOSPITAL ESTAOUSHMENTTYPE | DOR CVoetmis : nanuseor | Health Care Provider SECTOR ‘oovnment Pre BUSINESS ine Brgy. 5, BS. Aquino Drive, Bacolod City zecooe | 6100 vise pLavt a008ESS | Brgy. 5, BS. Aquino Drive, Bacolod City ze cove | 6100 EMAILADDRESS fivermedcenternet | tno. | (6334) 433-7331 nxn. | (6334) 464-5532 ENTITY'S REPRESENTATIVE INFORMATION THE OFREDOF | Genesis Goldi D. Golingan eer ORES [Miriam Hope D. Bravo DESIGNATION President and CEO DESIGNATION Director of Pharmacy Peas Unit 1, One Prestige Residences _ | HOWE ANDRESS [Eroreco Subd., Bacolod City EWA ADDRESS _genesisgoldid@gmail.com EWA ADDRESS Ihopebravo1966@gmail.com TEL NO /MOBLENO | 09200701594 TEL /MOBLENO, (0999-306-3335 NATONALTY Filipino NATIONALITY Filipino {IRSA {a reg nna, png MR AEF SINCAROTTRTOR TN] 5 A fa TWN 3.20 VERICATONSUP 6TH ‘Date Issued 7 pee Sa TIN ai eskanmaser) 12/26/91 5. Due bad (nine soi] n/a TNOTCLEARANCE | 7 & NBTCLENRANGE @ n/a fe Caras Finds no record found Da sued eel n/a ® ‘December 3, 2020 SLETTEROF i TRRCOCRD 7 ‘AUTHORIZATION ssuED 7a Region No. eee ON ogra) To. Regsraten Doo 11/23/1987 (ast tbmese) n/a nite 7 eet NOTARZEDJONT | ¥ TPIRTCOE brgpanmam —| Ba AFFIDAVIT SWMORNED ON fa PTRN. 8610084 (gra) £8 Dats January 08/2021 ENTITY'S INFORMATION TTNCAROTIR = 15. FORECAST FOR 5a pas Baca Sa TNO 000-425-345 FORTHCOMING YEAR Ongrer OD Mousware 1/0 8b. Date Issued & ‘16. CERTIFICATE OF PRODUCT | 16. For importers / manufacturers exporters only {one tre submission) 10/3/1991 REGISTRATION (CPR)! {one-time siémission) n/a iO OTTSe07coR ——] oe pices 0-008 =o RAR Ceti les of he a cae Pee ‘a Regtahan No 25472 1 Petues DORs n/a Pedagert 2 10. Vay 100 ‘ENTITY'S PROFI ‘17 (one-tme submsson) Ol ate TAT/1964 (Guy athe) nfa Tenet Yor 7 TE ORGANIZATION irae, aN STS compas etd September 24, 2020 STRUCTURE (iy autre tne staan) n/a oF "B-LOCATONTVICRITY MAP| 1 one ne ssn 12 wavors?euar 202071930 ate viscose 9/2 T% BH ROORFLUNNAYOUTTO 75 (oe tne amon) sta nro ; 8355750 HougusiouccwEs | otha viasnoy "74 4 Oral Rectno. | i Fret Von wh sige fre suas) 122 al sed dU September 8, 2020 ESTAOUSINENT Sloe ‘itwenowe 8/2 73 DOH TFOA LTO} Re 2, PROOF OF ONNERSHIPT 7. oe be ase) ‘12a. LTO Ceca & No. 06-0465-21-H3-2 LEASE CONTRACT Dotice Qwarcrouss n/a 18. Official Receipt No. 130, 23 PICTURE OF CONTROLLED | 23. (one-time submission) /: Te Dean n/a ‘SUBSTANCE’ STORAGE AREA ie aisterrdaedlareal Te ‘24. LATEST SEMI-ANNUAL Es Aeparingen ay) December 31, 2021 REPORT SUBMITED January 15, 2021 wocnocREDTaTON | n/a B.TRANSACTIONREGSTER |. cERTFICATE % ZHLATEST SUCENSE SUED | * \Fermparers exons on n/a 2a Sone te ‘030420001 - RO9S - G {ih oncalRecgmne. [FE paca mm ‘He Dao Vad Ut n/a March 28, 2021 |'SOLENNCY SWEAR hale Safemanis made on Ts Apgaton Fam aa Woe ad fa ached auporing oammenis are aun. Wis undusiood Ga he Enya ie esponee sinalry offers are bound fo comply wih the povons of RA S165, obese known as the, ‘Conprebensve Dangerous Drugs Act of 2007, and oer pertinent es and ‘equllons gamete by Ie Ppa ru Enorament Agency. Genesis Goldi D. Golingan Phintod Name and Signature of Head of fice M B Printed Name, Signature of Auhonzed Phamacis'Signalory