FM-CSVlrd-08

REPUBLIC OF THE PHILIPPINES )

CITY OF )

JOINT AFFIDAVIT

We,___________________and _________________ of legal ages, ________and___________, _______and _______

(Names ) (Citizenships) (Status)
and residing at and __________________________________________________,
(Addresses)
and employed as ___________________________________________ and ________________________________________ respectively,
(Designations)
by____________________________________________________________________________________________________________,
(Name and Address of Establishment)

after having been duly sworn in accordance with the law, do hereby depose and say:

That,________________________________________ is a [ ] new / [ ] renewal applicant for a PDEA License

(Name of Establishment)

to handle the following specified controlled chemicals and/or its mixtures:

Name of Controlled Chemicals Purpose of Handling Annual Projected Quantity Supplier/s

and/or its Mixtures (Importation / Exportation / Manufacture (of Importation/ Exportation/
(Indicate % concentration) / Repack / Recycle / Distribute / Retail / Manufacture/ Distribution/
End-use / Lab or Research Use Retail/ Consumption)
- choose activity as appropriate)

(use extra sheet, if necessary, (if for end-use / lab. use purposes,
and mark as annex) please provide details)

That, the above cited controlled chemicals and/or its mixtures shall be solely used for the legitimate purpose governing
the nature of the applicants legitimate existence, and in no case will it be diverted to illegal purposes.

(This paragraph is applicable for applicants with late renewal and/or late submission of Semi-Annual Report only).
That our PDEA License expired on _______________________________ and our latest Semi-Annual Report (SAR) for the period
covering January to June _______ / July to December _______ was submitted late to PDEA Compliance Service on
________________________ due to _____________________________________________________________________ (late renewal)
_____________________________________________________________________________________________________ (late SAR).

That, for and in behalf of our establishment and by virtue of this Affidavit, we hereby bind ourselves to all the
provisions of Republic Act 9165 otherwise known as the Comprehensive Dangerous Drugs Act of 2002, and its implementing Rules and
Regulations and assuring that such law and regulations shall be faithfully complied with;

That, we are executing this Affidavit to attest the truth of the foregoing facts, and for whatever legal intent and
purpose it may serve.

IN WITNESS HEREOF, we have hereunto set our hands this _____________day of __________________, 20______
at ______________________________________, Philippines.

Affiant Affiant
(Head/owner/GM/BM of company) (PDEA-Registered Signatory)

SUBSCRIBED AND SWORN to before me this ___________day of __________________________________, 20____at __________________________, Philippines.
Affiants personally exhibiting their [ ] Community Tax Certificate Nos. / [ ] valid Government-issued ID Nos. ___________________ and ___ issued
on______________and _____ at and , respectively.
NOTARY PUBLIC
Doc. No.
Page No.
Book No.
Series of

NOTE: WHEN ACCOMPLISHING THIS AFFIDAVIT, PLEASE DELETE TEXTS IN RED FONT.
FOR LATE RENEWAL AND /OR LATE SAR SUBMISSION PLEASE SUBMIT THREE (3) COPIES OF THIS AFFIDAVIT.
Rev_ 3_ May15, 2017