CPA Form Fertilizer and Pesticide Authority by liaoqinmei

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									                           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:

								
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