PLEASE PRINT CLEARLY. USE A BLACK BALLPEN. ALL THREE (3) COPIES MUST BE LEGIBLE.

NOT FOR SALE

TO BE FILLED OUT BY NFA

NATIONAL FOOD AUTHORITY NFA FORM NO. ISD-IRD 054-055/2009

APPLICATION FOR LICENSE/

DATE FILED Quezon City REGISTRATION
DAY MONTH YEAR
I HAVE THE HONOR TO APPLY FOR LICENSE/REGISTRATION FOR:
PLACE OF FILING : CURRENT YEAR 2ND YEAR 3RD YEAR
1 INDIVIDUAL
RURBAN CODE CONTROL NO. TAXPAYER'S IDENTIFICATION NO. (TIN) 2 ENTITIES
NAME OF APPLICANT LAST NAME GIVEN NAME MIDDLE NAME SEX M DATE OF BIRTH PLACE OF BIRTH CITIZENSHIP

F DAY MO YR

REGISTERED BUSINESS TRADE NAME PRINCIPAL PLACE OF BUSINESS (NO. & STREET, TOWN / CITY, PROVINCE) TEL. NUMBER

REGISTERED WITH : (pls. Check) DATE OF REGISTRATION

DAY MO YR
1 DTI 2 SEC 3 CDA 4 OTHERS (SPECIFY) ___________________
IF INDIVIDUAL : HOME ADDRESS OF THE APPLICANT (NO. & STREET, TOWN / CITY, PROVINCE) ZIP CODE TEL./MOBILE NUMBER

CITIZENSHIP ACQUIRED THRU 1 NATURAL BORN 2 MARRIAGE 3 ELECTION 4 NATURALIZATION 5 REPATRIATION 6 OPERATION OF LAW
CIVIL STATUS 1 SINGLE 2 MARRIED 3 SEPARATED 4 WIDOW/ER NAME OF SPOUSE CITIZENSHIP
FATHER'S NAME ADDRESS CITIZENSHIP TEL. NUMBER

MOTHER'S NAME ADDRESS CITIZENSHIP TEL. NUMBER

BUSINESS LINE OF ACTIVITY AND CAPITALIZATION (Pls. Indicate capitalization per line of activity per annum)
LINE OF ACTIVITY CAPITALIZATION LINE OF ACTIVITY CAPITALIZATION LINE OF ACTIVITY CAPITALIZATION
1. RETAILING P ________________ 9. INDENTING P ________________ 15. TRANSPORTING P ______________
2. WHOLESALING P ________________ 10. WAREHOUSING P ________________ 16. POST PRODUCTION EQUIPMENT P ______________
3. THRESHING P ________________ 11. MILLING 17. INSTITUTION / ESTABLISHMENT P ______________
4. CORN SHELLING P ________________ STATIONARY P ________________ 18. POULTRY / HOG RAISING P ______________
5. MANUFACTURING P ________________ TRAVELLING
19. MANUFACTURING/DISTRIBUTION
12. MECHANICAL OF POST HARVEST FACILITIES
P ______________
6. PROCESSING
P ________________ DRYING P ________________
7. EXPORTING P ________________ 13. PACKAGING P ________________ 20. MANUFACTURING/PROCESSING/
DISTRIBUTION OF IRON RICE PREMIX P ______________
8. IMPORTING P ________________ 14. MIST POLISHING P ________________
TOTAL CAPITALIZATION : P
IS THE APPLICANT WILLING TO BE A MEMBER OF ANY GRAINS ASSOCIATIONS? YES NO
IF YES, STATE NAME(S) OF ASSOCIATION
HAVE YOU ATTENDED NFA SPONSORED TRAININGS ? YES NO
IF YES, STATE TITLE OF TRAININGS
HAS THE APPLICANT ENTERED INTO ANY CONTRACT WITH NFA? YES NO
IF YES, STATE NATURE OF CONTRACT
HAS THE APPLICANT BEEN CHARGED OR DEEMED TO HAVE VIOLATED ANY PROVISION OF PRESIDENTIAL DECREE NO. 4 AS AMENDED AND OTHER PERTINENT LAWS, REVISED RULES
AND REGULATIONS, ORDERS, DIRECTIVES, CIRCULARS OR MEMORANDA OF NFA? YES NO
IF YES, STATE NATURE OF VIOLATION(S)
I HEREBY CERTIFY THAT THE FOREGOING DATA AND INFORMATIONINCLUDING PRINT NAME & SIGN
THOSE IN THE ANNEXES ARE TRUE TO THE BEST OF MY KNOWLEDGE AND DO
HEREBY SWEAR THAT I HAVE BEEN PROPERLY APPRISED OF MY DUTIES AND
OBLIGATION UNDER THE NFA'S RULES AND REGULATIONS AND CIRCULARS _____________________________________________
ISSUED BY THE NATIONAL FOOD AUTHORITY AND THAT I SHALL ENDEAVOR TO SIGNATURE OVER PRINTED NAME OF THE APPLICANT/
COMPLY FULLY WITH THE SAME. AUTHORIZED REPRESENTATIVE

(TO BE FILLED OUT BY NFA)

APPLICATION FEE REMARKS

O.R. NO.

O.R. DATE
LICENSE / REGISTRATION FEE/S
1. RETAILING P ________________ 10. WAREHOUSING P ________________ 17. INSTITUTION / ESTABLISHMENT P ________________
2. WHOLESALING P ________________ 11. MILLING 18. POULTRY / HOG RAISING P ________________
3. THRESHING P ________________ STATIONARY P ________________ 19. MANUFACTURING/DISTRIBUTION
OF POST HARVEST FACILITIES P ________________
4. CORN SHELLING P ________________ TRAVELLING P ________________
12. MECHANICAL
5. MANUFACTURING P ________________ P ________________ 20. MANUFACTURING/PROCESSING
DRYING P ________________
DISTRIBUTION OF IRON RICE PREMIX
6. PROCESSING P ________________ 13. PACKAGING P ________________
7. EXPORTING P (FEE ABOLISHED) 14. MIST POLISHING P ________________ 21. CASH BOND P ________________
8. IMPORTING P ________________ 15. TRANSPORTING P ________________ 22. SURCHARGE P ________________
16. POST
9. INDENTING P ________________ P ________________ 23. OTHERS P ________________
PRODUCTION
O.R. NUMBER : O.R. DATE : TOTAL FEES PAID : P
DATE PROCESSED BY : PROV'L. RLO PROV'L. MGR. / OIC
DATE APPROVED
DAY MO. YR.
DAY MO. YR.
DAY MO. YR. REVIEWED BY : REG'L. RLO