Prk Document Title [Form No. [P-022 RE even xa —fr FPA APPLICATION FOR REGISTRATION OF APESTICIDE — (24e— — = ¥ PRODUCT [Approved by .M. Romualdez Page oft ‘Reminder: Please fillout this form completely and legibly, PLEASE ATTACH ALL REQUIRED DATA AS SPECIFIED IN OUR REGULATORY POLICIES AND GUIDELINES [GREEN BOOK] 1. NAME AND ADDRESS OF APPLICANT Date Received Date Processed JAmount Paid 2. BRAND NAME — [OR Number [oR Date, ENAME OF ACTIVETNGREDIENT AND PERCENT PURITY “FFORMULATION : % ACTIVE INGREDIENT & TYPE 5. REGISTRATION APPLIED FOR: NEW ___NEWW/TPA RENEWAL, RESUBMISSION USE CATEGORY 7.NAME & ADDRESS OF MANUFACTURER INSECTICIDE HERBICIDE FUNGICIDE OTHERS (SPECIFY) 8, NAME & ADDRESS OF FORMULATOR ‘9: PACKAGING SIZES: 10, PROPOSED USE RECOMMENDED DOSAGE ROP (5) PEST (S) ALA ‘TBS/16L PRODUCT/HA (KGOR LI) (aoccryrBs) (KGORL) (USE ADDITIONAL SHEETS, IF NECESSARY.) TL. APPLICANT'S REPRESENTATIVE: NAME, TITLE, SIGNATURE 12, APPLICANT'S EMAIL ADDRESS TS. PRIVACY NOTICE AND CONSENT TO USE DATA We respect your privacy and keep your personal information confidential unless we are lawfully required or allowed to disclose itor ‘that you give your written consent to such disclosure. 14. CONSENT TO PROCESS AND SHARE DATA In compliance with the Data Privacy Act, I hereby give my consent to the Fertilizer and Pesticide Authority to share my contact, details to the public for whatever legal purpose it may serve. ‘Signature over Printed Name of the Contact Person REPUBLIC OF THE PHILIPPINES PROVICE OF MUNICIPALITY OF. ‘SUBSCRIBED AND SWORN TO before me this day of year__at Phillippines, affiant exhibited to me his/her Residence Certificate No, issued on vyear__, at. Phillippines, NOTARY PUBLIC Until PTRNo,