Form Dtl-Coa-Af-2007 - Application For Accreditation Of Drug Testing Laboratory Page 2
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4Form DTL-COA-AF-2007
A
B
C
Documents
For Initial
For Renewal
8.
Quality Control Program (for screening laboratory) OR
Certification for Quality Standard System by a DOH recognized certifying body (for
confirmatory laboratory)
9.
Certificate of Proficiency/ Proficiency Testing Result
10. Procedure Manual
11. Contract of Lease (if site is rented)
12. Location Map for the laboratory building
13. Photographs of the exterior and interior of the laboratory
14. Floor Layout with appropriate scale reflecting properly labeled areas to include
spatial relationship with adjacent areas if present
15. DTI/ SEC Registration (for private laboratory) OR
Issuance or Board Resolution (for government laboratory)
16. Photocopy of DOH Certificate of Accreditation
Acknowledgement
REPUBLIC OF THE PHILIPPINES
)
CITY/ MUNICIPALITY OF ______________ ) S.S.
I,
______________________________,
____________,
of
legal
age,
__________,
a
resident
of
Civil Status
Age
Name
___________________________________________, after having been sworn in accordance with law hereby depose and
Address
say that I am executing this affidavit to attest to the completeness and truth of the foregoing information and the attached
documents required for the Registration and Accreditation of Drug Testing Laboratory pursuant to R.A. 9165
“Comprehensive Dangerous Drugs Act of 2002”.
_________________________
Signature
Before me, this _________day of ______________ 2007 in the City/ Municipality of ________________,
Philippines, personally appeared
Owner
Community Tax Number
Issued at/ on
_____________________________
_____________________________
_____________________________
known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is
their free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 2007.
Doc. No. _____________________
NOTARY PUBLIC
Page No. _____________________
My Commission Expires
Book No. _____________________
Dec. 31. 200___
Series of _____________________
Page 2 of 4
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