PHILIPPINE DRUG ENFORCEMENT AGENCY

Form: S2LA-2009
Rm 213 (Compliance Service), PDEA Building, NIA Northside Road, Bgy. Pinyahan, Q.C. 1100
Tel. No. 927-9702 loc. 198, 197 / Telefax 920-8110
Email: pdea_cs@yahoo.com.ph / Website: pdea.gov.ph
APPLICATION SHEET (S2- LICENSE)
APPLICATION FOR REGISTRATION TO PRESCRIBE DANGEROUS DRUG PREPARATIONS
&/OR DRUG PREPARATIONS CONTAINING TABLE 1 CONTROLLED CHEMICALS
AS PRACTITIONERS (Physician / Dentist / Veterinarian)
Date
MARK APPROPRIATE BOXES  WITH √  NEW  RENEWAL  LOST ID  Paper ID  PVC ID
FILL OUT BLANKS. TYPE OR PRINT LEGIBLY. ONLY SIGNED FORMS WITH COMPLETE DOCUMENTS WILL BE PROCESSED.
SURNAME
NAME EXTENSION
FIRST NAME (e.g. Jr., Sr.)

MIDDLE NAME

MOTHER'S MAIDEN NAME

Preferred Login Name (nmt 10 characters) EMAIL ADDRESS

DATE OF BIRTH MOBILE NO.

(mm / dd / yyyy) RESIDENTIAL

SEX  Male  Female ADDRESS

 Single  Widowed
CIVIL STATUS  Married  Separated ZIPCODE
 Annulled  Others, TEL. NO. FAX NO.

 Physician HOSPITAL
PROFESSION
 Veterinarian ADDRESS
 Dentist
 ZIPCODE
SECTOR  Government  Private TEL. NO. FAX NO.
REQUIREMENTS (SUBMIT CLEAR DULY-CERTIFIED TRUE COPY. PRESENT ORIGINAL COPY FOR VALIDATION):
S2 ID CARD (original for surrender) 1a TIN ID CARD / LATEST ITR 4a
1a. S2 License # 4 4a. TIN
RENEWAL

1b 4b
1
ONLY

4b. Date Issued

FOR

1b. Date Issued

1c DRUG TEST 5a
1c. Valid Until NEGATIVE
5a. Drug Test Result
FOR LOST ID: Submit proof of publication of loss 5b. Date Issued 5b
PRC ID CARD 2a 5c
5c. Name of Accredited
2a. PRC License # 5
2b Drug Testing Center
2 2b. Date Issued
2c 5d. Drug Testing Center
2c. Validity 5d
Address
PTR 3a
3a. PTR O.R. #
3b 6 taken not later than 6 months from application,
3b. Date Issued 6 1 Pc 1" x 1" & 1 pc 2" x 2" ID picture
3 wearing of eyeglasses not allowed 
with white background
FOR GOVERNMENT PHYSICIANS: Submit latest Certificate of Employment in lieu of PTR and original notarized affidavit attesting that S2 license shall be used exclusively
for government practice only. Government practitioners are exempted from registration fee.
I SOLEMNLY SWEAR that the statements made on this Application Form are true and the attached
supporting documents are authentic. It is understood that I am bound to comply with the provisions
of RA 9165, otherwise known as the 'Comprehensive Dangerous Drugs Act of 2002' and other
pertinent rules and regulations implemented by the Philippine Drug Enforcement Agency. Printed Name and Signature of Applicant
RECOMMEND APPROVAL: Note: Expiration of S2 license is adjusted to coincide with the PRC ID Card validity.
S2 LICENSE Paid Under
Official Receipt Number :
Date:
Director, Compliance Service Amount: