FM-CSVlrd-01 Rev_4_May 01, 2023

Republic of the Philippines

Office of the President
PHILIPPINE DRUG ENFORCEMENT AGENCY
Compliance Service
PDEA Bldg. NIA Northside Road, National Government Center, Barangay Pinyahan,
Quezon City 1100 | (02) 8927-9702 local 197 & 198 : (02) 8920-8110 : cs@pdea.gov.ph
pdea.gov.ph PDEA Top Stories PDEA@PdeaTopStories pdeatopstories

S2 APPLICATION FORM
(Physician / Dentist / Veterinarian)
ALL FIELDS ARE REQUIRED/MANDATORY. INDICATE N/A IF NOT APPLICABLE.
MARK THE BOX APPROPRIATELY WITH A CHECK (  ). KINDLY USE BLACK OR BLUE INK.
ONLY APPLICATION WITH COMPLETE REQUIREMENTS AND CORRECT INFORMATION WILL BE PROCESSED.

TYPE OF APPLICATION  NEW  RENEWAL  LOST DATE OF APPLICATION

NAME EXTENSION
SURNAME
(e.g. Jr., Sr.)

FIRST NAME

MIDDLE NAME
MOTHER’S MAIDEN NAME
(mother’s surname at birth)

DATE OF BIRTH (mm/dd/yyyy) EMAIL ADDRESS

GENDER  Male  Female MOBILE NUMBER:

 Single  Widowed  Physician

CIVIL STATUS  Married  Separated PROFESSION  Veterinarian
 Annulled  Others ______________  Dentist

COMPLETE RESIDENTIAL
ADDRESS
NAME OF HOSPITAL/CLINIC
(do not abbreviate)
COMPLETE HOSPITAL/CLINIC
ADDRESS
SPECIALIZATION /
SECTOR  Government  Private
DEPARTMENT (for Physicians only)

PLEASE INPUT YOUR DETAILS AS PRINTED ON YOUR ATTACHED CLEAR SCANNED COPY/PHOTO OF DOCUMENTS.
1. S2 LICENSE CERTIFICATE
1a. S2 License No.: 4a.Drug Test Result: NEGATIVE
(For renewal applicants only)
FOR LOST OF VALID S2 LICENSE
CERTIFICATE, SUBMIT AFFIDAVIT OF 1b. Valid Until: 4. VALID DRUG TEST IN DOH-DDB 4b. Transaction Date:
LOSS IDTOMIS GENERATED REPORT OR
FROM GOVERNMENT FORENSIC 4c. Complete Name of the DOH Accredited Drug
2a. Registration No.: Testing Center:
LABORATORY
2. VALID PRC ID CARD
2b. Valid Until:

IN LIEU OF THE VALID PRC ID CARD, SUBMIT ANY THE FOLLOWING:

NEW APPLICANT: Certificate of Good Standing
RENEWAL APPLICANT: a. Application for Professional Identification Card with
signature and proof of payment 2” X 2” ID PICTURE
b. PRC Official Receipt with the current PRC ID Card 5. 1 PC 2” X 2” ID PICTURE
c. Certificate of Good Standing (white background, no eyeglasses,
(white background, no eyeglasses,
taken not more than 6 months from taken not more than 6 months from
Validity of S2 License is harmonized with the PRC license
date of application)
date of application)
3. NOTARIZED AFFIDAVIT attesting that S2 license shall be used exclusively for
government practice only (FM-CSVlrd-63)
(For government medical practitioners who will avail of exemption of fees)

I hereby attest and certify that the information provided on this application form are true and correct based on my personal knowledge. Further, the attached supporting
documents are AUTHENTIC records. It is understood that I am bound to comply with the pertinent provisions of R.A. 9165, as well as relevant regulations promulgated by the
Dangerous Drugs Board (DDB). Lastly, I hereby bound myself to be criminally liable for violation of the provision of the revised penal code for non-compliance of the above
requirements.

________________________________________
Printed Name and Signature of Applicant
THIS PORTION IS TO BE FILLED OUT BY THE PDEA S2 REGULATORY COMPLIANCE OFFICER
Processed by: Encoded by:
________________________________ ________________________________
Printed Name and Signature Printed Name and Signature
 CLIENT’S DATA PRIVACY CONSENT FORM

PDEA Compliance Service adheres and complies with the Data Privacy Act of 2012 (RA No. 10173) and its
Implementing Rules and Regulations (IRR) to safeguard Client’s Data Privacy Rights.
The herein named Client, by signing this Consent Form, it is construed that in his / her application for S2 License / S License /
P License / Accreditation as Transporter / Import/ Export Permit/ Special Permit and other transactions; has agreed and
consented to the following:
 Allow PDEA Compliance Service and its authorized representatives to collect, use, process and share pertinent
Data collected with other Government regulatory agencies the following information;
for S2 license Application – Name/Home and Office/Clinic Address/Contact No./Email/Birthdate/PRC ID/Drug Test
Result/signature.
for S/P license /Accreditation Application – Name/Home and Office Address/Email/Contact No./PRC ID/Business
permit/SEC Registration/FDA LTO/BOC Accreditation/signature.
 Allow PDEA Compliance Service to use/ share relevant Data for statistical research, and other lawful purposes;
 All Records and relevant data collected will be stored/ disposed of in a manner in accordance with applicable laws
and policies of the National Archives of the Philippines (NAP).

Conforme:

__________________________________________ _______________________
Name and Signature of Applicant Date Signed