FM-CSVlrd-01 S2 Application Rev 4 May 01 2023 28apr2023

FM-CSVlrd-01 Rev_4_May 01, 2023
Republic of the Philippines

Office of the President
PHILIPPINE DRUG ENFORCEMENT AGENCY
Compliance Service
PDEA Bldg. NIA Northside Road, National Government Center, Barangay Pinyahan,
Quezon City 1100 | (02) 8927-9702 local 197 & 198 : (02) 8920-8110 : [email protected]
pdea.gov.ph PDEA Top Stories PDEA@PdeaTopStories pdeatopstories
S2 APPLICATION FORM
(Physician / Dentist / Veterinarian)
ALL FIELDS ARE REQUIRED/MANDATORY. INDICATE N/A IF NOT APPLICABLE.
MARK THE BOX APPROPRIATELY WITH A CHECK (  ). KINDLY USE BLACK OR BLUE INK.
ONLY APPLICATION WITH COMPLETE REQUIREMENTS AND CORRECT INFORMATION WILL BE PROCESSED.
TYPE OF APPLICATION  NEW  RENEWAL  LOST DATE OF APPLICATION
ESTRADA NAME EXTENSION

SURNAME
(e.g. Jr., Sr.)
FIRST NAME
RACHEL MAE
MIDDLE NAME
BALCARSE
MOTHER’S MAIDEN NAME AGNES GARCIA BALCARSE
(mother’s surname at birth)
DATE OF BIRTH (mm/dd/yyyy) 11/27/1990 EMAIL ADDRESS
GENDER  Male  Female MOBILE NUMBER:
 Single  Widowed  Physician

CIVIL STATUS  Married  Separated PROFESSION  Veterinarian
 Annulled  Others ______________  Dentist
COMPLETE RESIDENTIAL
ADDRESS BLK 5 LOT 2 MAGNOLIA ST. GREENLAND EXECUTIVE VILLAGE CAINTA RIZAL
NAME OF HOSPITAL/CLINIC
NATIONAL CHILDRENS HOSPITAL
(do not abbreviate)
COMPLETE HOSPITAL/CLINIC 264 E. RODRIGUEZ SR. AVE NEW MANILA QUEZON CITY
ADDRESS
SPECIALIZATION /
SECTOR  Government  Private
DEPARTMENT (for Physicians only) PEDIATRICS
PLEASE INPUT YOUR DETAILS AS PRINTED ON YOUR ATTACHED CLEAR SCANNED COPY/PHOTO OF DOCUMENTS.
1. S2 LICENSE CERTIFICATE
1a. S2 License No.: 038707EM21-001 4a.Drug Test Result: NEGATIVE
(For renewal applicants only)
FOR LOST OF VALID S2 LICENSE
CERTIFICATE, SUBMIT AFFIDAVIT OF 1b. Valid Until: 11/27/2023 4. VALID DRUG TEST IN DOH-DDB 4b. Transaction Date:
LOSS IDTOMIS GENERATED REPORT OR
FROM GOVERNMENT FORENSIC 4c. Complete Name of the DOH Accredited Drug
2a. Registration No.: Testing Center:
LABORATORY
2. VALID PRC ID CARD
2b. Valid Until: 11/27/2026
IN LIEU OF THE VALID PRC ID CARD, SUBMIT ANY THE FOLLOWING:

NEW APPLICANT: Certificate of Good Standing
RENEWAL APPLICANT: a. Application for Professional Identification Card with
signature and proof of payment 2” X 2” ID PICTURE
b. PRC Official Receipt with the current PRC ID Card 5. 1 PC 2” X 2” ID PICTURE
c. Certificate of Good Standing (white background, no eyeglasses,
(white background, no eyeglasses,
taken not more than 6 months from taken not more than 6 months from
Validity of S2 License is harmonized with the PRC license
date of application)
date of application)
3. NOTARIZED AFFIDAVIT attesting that S2 license shall be used exclusively for
government practice only (FM-CSVlrd-63)
(For government medical practitioners who will avail of exemption of fees)
I hereby attest and certify that the information provided on this application form are true and correct based on my personal knowledge. Further, the attached supporting
documents are AUTHENTIC records. It is understood that I am bound to comply with the pertinent provisions of R.A. 9165, as well as relevant regulations promulgated by the
Dangerous Drugs Board (DDB). Lastly, I hereby bound myself to be criminally liable for violation of the provision of the revised penal code for non-compliance of the above
requirements.
________________________________________
Printed Name and Signature of Applicant
THIS PORTION IS TO BE FILLED OUT BY THE PDEA S2 REGULATORY COMPLIANCE OFFICER
Processed by: Encoded by:
________________________________ ________________________________
Printed Name and Signature Printed Name and Signature
CLIENT’S DATA PRIVACY CONSENT FORM
PDEA Compliance Service adheres and complies with the Data Privacy Act of 2012 (RA No. 10173) and its
Implementing Rules and Regulations (IRR) to safeguard Client’s Data Privacy Rights.
The herein named Client, by signing this Consent Form, it is construed that in his / her application for S2 License / S License /
P License / Accreditation as Transporter / Import/ Export Permit/ Special Permit and other transactions; has agreed and
consented to the following:
 Allow PDEA Compliance Service and its authorized representatives to collect, use, process and share pertinent
Data collected with other Government regulatory agencies the following information;
for S2 license Application – Name/Home and Office/Clinic Address/Contact No./Email/Birthdate/PRC ID/Drug Test
Result/signature.
for S/P license /Accreditation Application – Name/Home and Office Address/Email/Contact No./PRC ID/Business
permit/SEC Registration/FDA LTO/BOC Accreditation/signature.
 Allow PDEA Compliance Service to use/ share relevant Data for statistical research, and other lawful purposes;
 All Records and relevant data collected will be stored/ disposed of in a manner in accordance with applicable laws
and policies of the National Archives of the Philippines (NAP).
Conforme:
__________________________________________ _______________________
Name and Signature of Applicant Date Signed

FM-CSVlrd-01 S2 Application Rev 4 May 01 2023 28apr2023

Uploaded by

Copyright:

Available Formats

FM-CSVlrd-01 S2 Application Rev 4 May 01 2023 28apr2023

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

FM-CSVlrd-01 S2 Application Rev 4 May 01 2023 28apr2023

Uploaded by

Copyright:

Available Formats

FM-CSVlrd-01 Rev_4_May 01, 2023

Republic of the Philippines

TYPE OF APPLICATION  NEW  RENEWAL  LOST DATE OF APPLICATION

ESTRADA NAME EXTENSION

DATE OF BIRTH (mm/dd/yyyy) 11/27/1990 EMAIL ADDRESS

GENDER  Male  Female MOBILE NUMBER:

 Single  Widowed  Physician

IN LIEU OF THE VALID PRC ID CARD, SUBMIT ANY THE FOLLOWING:

You might also like