Docstoc

CPA Form Fertilizer and Pesticide Authority

Document Sample
CPA Form Fertilizer and Pesticide Authority Powered By Docstoc
					                           REPUBLIC OF THE PHILIPPINES
                           DEPARTMENT OF AGRICULTURE
                           FERTILIZER AND PESTICIDE AUTHORITY
                           FPA BLDG. B.A.I. Compound Visayas Ave. Diliman Q.C.
                           Tel. Nos.: 922-3371 / 922-33-55 / 922-3362 / 922-3368
                           Telefax:     922-3355
                           Web site: http://fpa.da.gov.ph Email Add: fpa_77@yahoo.com


                         CERTIFIED PESTICIDE APPLICATORS
                         ( ) FUMIGATOR / ( ) EXTERMINATOR
                         (APPLICATION FOR ACCREDITATION)
                                                                            ID Picture


PERSONAL DATA

  Name:                                                Age:
  Sex:                                                 Civil Status:
          ( ) Manle ( ) Female                         ( ) Single      ( ) Married
  Address:
  Tel. No.

BUSINESS DATA

  Name of Store / Establishment:


  Address of Store / Establishment:


  Name of Owner / Proprietor:


  TRAINING ATTENDED:

     Venue:
     Date: ______________________          Rating:
     Ref. No.: ___________________

  ACCREDITATION APPLIED:
    ( ) Exterminator                       ( ) Fumigator
    ( ) New                                ( ) Renewal


                                              Signature of Applicant

  REQUIREMENTS:
  1. Processing Fee – P600.00
  2. Certificate of Employment
  3. Monthly Pest Control Operation Report (In-house CPA’s)
  4. List of Chemicals Used (Renewal)
  5. Certificate of Attendance to one Symposium (Renewal)


  For FPA Use Only:

  Date Received:                               Expiry Date:
  Amount Paid:                                 Date:
  O.R. No.:                                    ID No.:
  Date Processed:                              Control No:
  Date Released:

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:16
posted:11/2/2011
language:English
pages:1