Form Qwp-Cdrrhr-4-01-Annex 2.3 - Application Form For A License To Operate A Non-Medical X-Ray Facility Page 2
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1
2
3Republic of the Philippines
Department of Health
Food and Drug Administration
CENTER FOR DEVICE REGULATION,
RADIATION HEALTH, AND RESEARCH
Form
No.:x
QWP-CDRRHR-4-01-Annex 2.3
Revision:x
01
APPLICATION FORM FOR A LICENSE TO OPERATE A NON-MEDICAL X-RAY FACILITY
General Instructions: Write legibly and in BLOCK letters. Put an “x” mark on appropriate tick box. Completely fill-up
the required information and signatures. The CDRRHR will not receive and process unduly filled-up application forms.
For requirements, please refer to the attached checklist.
TYPE OF AUTHORIZATION
For CDRRHR use
New application
Renewal of LTO
Amendment to existing LTO # _____________
Reference No:
Reason/s for amendment:__________________
__________________
Thru mail
TYPE OF NON-MEDICAL X-RAY FACILITY
Walk-in
Industrial
Anti-crime
Research
Attachments:
I General Information
Check.
Name of Facility :__________________________________________________________________
PMO
Facility Address :__________________________________________________________________
No. : _____________
__________________________________________________________________
Amount: __________
Contact No./s
:__________________________________________________________________
Fee Paid
PHP:______________
Name and Address of the Applicant (Legal Person), Company, Organization, etc.
O.R #:_____________
Name :______________________________
Position/Designation:______________________
Date Paid:__________
Address : ____________________________________________-
_____________________________
Received by:
Contact No./s.___________________________
Email Address : ______________________
__________________
Date :_____________
Time: _____________
II Name and qualifications of the personnel working in the x-ray facility
Evaluation:
Radiation Protection Officer (RPO)
Date Received:______
Time: _____________
Name
:_________________________________
Remarks:
Qualification : _________________________________
________________
SIGNATURE:
________________
________________
________________
________________
________________
III Declaration of the veracity of information: To be signed by the legal person/owner
________________
________________
I hereby declare that all the information provided on the form and in support of this application
________________
is to the best of my knowledge complete and true in every particular.
Recommending
Approval:
__________________________
__________________
Printed Name and Signature
____________
Date:
Position:___________________
Date: _____________________
__________________
Encoded by:
Date:______________
Page 1 of 2
_______________________________________________________________________________________________
Building 24, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Telefax Nos. (632)711-60-16, Trunk Line: (632)651-78-00 local 3401 to 05, 3408 to 12
URL: e-mail: apperalta@co.doh.gov.ph
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