Republic of the Philippines

Department of Agriculture
BUREAU OF ANIMAL INDUSTRY
Visayas Ave., Diliman, Quezon City
TIN NO.: 300-000-746-316
VETERINARY DRUG AND PRODUCT (VDAP) REGISTRATION
ANNEX FORM

VDAP REF NO: ______________________

Date: ______________________________

Director Date: ______________________________

Bureau of Animal Industry
Visayas Avenue, Diliman
Quezon City

Attention: ANIMAL FEEDS, VETERINARY DRUGS AND BIOLOGICS CONTROL DIVISION (AFVDBCD)
Registration, Licensing and Certification Section (RLCS)

Sir/Madam:

In accordance with Republic Act (RA) 3720, Joint Administrative Order (JAO) between the Department of Agriculture (DA) and
the Department of Health (DOH) 2013-0026 and the other related issuance, we wish to apply for the ( ) initial ( ) Renewal of our
Products Registration for:

Approved Generic Name

Brand Name
Dosage Strength per unit
Dosage Form
Primary Packaging (market or commercial Presentation)
License to Operate No and Expiry Date
Name of Company Applicant

Enclosed are the documents started in the checklist of Requirements for the Registration.

We categorically declare that all data in formation submitted in connection with this application as well as other submission in the
future are true and correct and reflect the total information available.

We hereby agree and affirm to indemnity and/or hold the BAI free from any or all Third Party Claims (TPC) on infringement of
patent/trademark and any distribution disputes arising from the registration of the Veterinary Drug and Product(s) concerned.

Respectfully yours,

(Printed Name and Signature of Authorized Representative)

VETERINARY MEDICAL OFFICER COMPANY PHARMACIST

Signature ____________________________ Signature ___________________________
Name (print or type): ___________________ Name (print or type): ___________________
Lic. No.______________________________ Lic. No._____________________________
PTR No.______________________________ PTR No._____________________________

OWNER/GENERAL MANAGER
Signature ______________________
Name (print or type): ____________________________

ACKNOWLEDGMENT

SUBSCRIBED AND SWORN to before me this ___________________________________________

Personally appeared the following:

Name Community Tax Certificate Date of Issued Place Issued

Known to me and to be the same persons who executed the foregoing instruments and they acknowledged to me that the same
is their free and voluntary act and deed.

WITNESS MY HAND AND SEAL on the date and place first above written.

Doc: ______________________
Page No: __________________ NOTARY PUBLIC
Book No: __________________
Series No: _________________

RF FVDB-17 Initial/Renewal VDAP Registration Annex Form

Revision No. 02
September 19, 2019