Annex E Assessment Slip Food
2
PAICS COPY ACCOUNTING SECTION’S COPY Annex E Bureau of Food and Drugs Policy, Planning, and Advocacy Division ASSESSMENT SLIP FOOD DATE: RSN: Applicant Company : _______________________________________________________ Address/Tel no. : _______________________________________________________ LTO No./Validity : _______________________________________________________ Manufacturer Distributor/Wholesaler Importer Exporter Wholesaler PRODUCT INFORMATION Brand name and Product Name : Product Classification (Category/Code) : List of Products : Number of Products Applied : Packaging Types and Sizes : Registration Number (FR) : __________________ Validity: ___________________________________ Applicant Company : Manufacturer : Repacker : Distributor : Others (Pls. specify) : Number of Samples : __________________ Loose Labels:_______________________________ APPLICATION DETAILS Application Type Category I Category II Food Supplemen t Bottled Water Initial Renewal Renewal with Surcharge Re-application (OLD RSN:_______________) No. of CPR Validity Applied for (year/s) OTHER REQUESTS Bureau of Food and Drugs Policy, Planning, and Advocacy Division ASSESSMENT SLIP FOOD DATE: RSN: Applicant Company : _______________________________________________________ Address/Tel no. : _______________________________________________________ LTO No./Validity : _______________________________________________________ Manufacturer Distributor/Wholesaler Importer Exporter Wholesaler PRODUCT INFORMATION Brand name and Product Name : Product Classification (Category/Code) : List of Products : Number of Products Applied : Packaging Types and Sizes : Registration Number (FR) : __________________ Validity: __________________________________ Applicant Company : Manufacturer : Repacker : Distributor : Others (Pls. specify) : Number of Samples : __________________ Loose Labels:_______________________________ APPLICATION DETAILS Application Type Category I Category II Food Supplemen t Bottled Water Initial Renewal Renewal with Surcharge Re-application (OLD RSN:_______________) No. of CPR Validity Applied for (year/s) OTHER REQUESTS
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FDA Assessment
Transcript of Annex E Assessment Slip Food
PAICS COPY ACCOUNTING SECTION’S COPY Annex E
Bureau of Food and DrugsPolicy, Planning, and Advocacy Division
A S S E S S M E N T S L I PFOOD
DATE: RSN:
Applicant Company : _______________________________________________________ Address/Tel no. : _______________________________________________________ LTO No./Validity : _______________________________________________________ Manufacturer Distributor/Wholesaler Importer Exporter Wholesaler PRODUCT INFORMATION
Brand name and Product Name :Product Classification (Category/Code) :
List of Products :
Number of Products Applied :
Packaging Types and Sizes :
Registration Number (FR) : __________________ Validity: ___________________________________
Applicant Company :
Manufacturer :
Repacker :
Distributor :
Others (Pls. specify) :
Number of Samples : __________________ Loose Labels:_______________________________APPLICATION DETAILS
Application TypeCategory
ICategory
IIFood
SupplementBottled Water
Initial Renewal Renewal with Surcharge Re-application (OLD RSN:_______________) No. of CPR Validity Applied for (year/s)
OTHER REQUESTS Amendment of CPR Provisional Permit to Market (PPM) Re-issuance/Reconstruction of CPR Export Certificate Referral to ACB Others, pls. specify
PAYMENT DETAILS
EVALUATOR CASHIER
Fee : Amount :
Surcharge : OR Number :
TOTAL : Date Issued :
Evaluated by : Received by :
RECEIPT DETAILS
Name :
Signature :KJFSLFJASKFJALDFJLAFJLSKDJFLAKSJDFLJASKDFJALSD
Bureau of Food and DrugsPolicy, Planning, and Advocacy Division
A S S E S S M E N T S L I PFOOD
DATE: RSN:
Applicant Company : _______________________________________________________ Address/Tel no. : _______________________________________________________ LTO No./Validity : _______________________________________________________ Manufacturer Distributor/Wholesaler Importer Exporter Wholesaler PRODUCT INFORMATION
Brand name and Product Name :Product Classification (Category/Code) :
List of Products :
Number of Products Applied :
Packaging Types and Sizes :
Registration Number (FR) : __________________ Validity: __________________________________
Applicant Company :
Manufacturer :
Repacker :
Distributor :
Others (Pls. specify) :
Number of Samples : __________________ Loose Labels:_______________________________APPLICATION DETAILS
Application TypeCategory
ICategory
IIFood
SupplementBottled Water
Initial Renewal Renewal with Surcharge Re-application (OLD RSN:_______________) No. of CPR Validity Applied for (year/s)
OTHER REQUESTS Amendment of CPR Provisional Permit to Market (PPM) Re-issuance/Reconstruction of CPR Export Certificate Referral to ACB Others, pls. specify
PAYMENT DETAILSEVALUATOR CASHIER
Fee : Amount :
Surcharge : OR Number :
TOTAL : Date Issued :
Evaluated by : Received by :
RECEIPT DETAILS
Name :
Signature :KJFSLFJASKFJALDFJLAFJLSKDJFLAKSJDFLJASKDFJALSD
PAICS COPY ACCOUNTING SECTION’S COPY Annex E
