BHFS Form No.

4-01 November 2004

Republic of the Philippines

Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Bldg. 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila

APPLICATION FOR PERMIT TO CONSTRUCT A

CLINICAL LABORATORY

Name of Applicant:
(Owner/Administrator)
Address of Applicant:
Name of Laboratory:
Complete Address of the Laboratory:

TYPE OF APPLICATION

[ ] Classification According to:

Ownership Service Capability
[ ] Government [ ] Primary
[ ] Private [ ] Secondary
[ ] Tertiary
[ ] Change in Classification from __________________ to __________________

CHECKLIST OF DOCUMENTS

[ ] Form No. 4-01: Application for Permit to Construct notarized

[ ] Letter of Application to the Director of the Bureau of Health Facilities and Services
[ ] Letter of Endorsement from the Director of the Center for Health Development
[ ] Four (4) Sets of Floor Layout, showing location of equipment and areas required,
appropriately dimensioned, properly identified and completely labeled
[ ] DTI/SEC Registration (for private clinical laboratory)

________________________________
Applicant
Signature above Printed Name
Date__________

Documents Checked by: ____________________

A COPY OF PERMIT TO CONSTRUCT AND APPROVED FLOOR LAYOUTS SHALL BE ISSUED WITHIN 15
WORKING DAYS UPON RECEIPT OF APPLICATION PROVIDED THAT ALL DOCUMENTS ARE
COMPLETE AND COMPLIANT.