FM-CSVlrd-01 S2 Application Rev 0 April 30 2018 02AUG2018

Republic of the Philippine FM-CSVlrd-01 (page 1 of 2)
Office of the President

PHILIPPINE DRUG ENFORCEMENT AGENCY
COMPLIANCE SERVICE
PDEA Bldg. NIA Northside Road, National Government Center, Barangay Pinyahan,
Quezon City 1100 | Email: cs@pdea.gov.ph / www.pdea.gov.ph | (02) 927-9702 loc. 197/198 / 920-8110
S2 APPLICATION FORM FOR REGISTRATION OF MEDICAL PRACTITIONERS

(Physician / Dentist / Veterinarian) Rev_0_April 30, 2018
ONLY DULY FILLED-OUT AND SIGNED FORM WITH COMPLETE REQUIREMENTS WILL BE PROCESSED
Date:
MARK APPROPRIATELY BOXES WITH √  NEW  RENEWAL  LOST
FOR RENEWAL APPLICANTS THRU A REPRESENTATIVE, PLEASE FILL-OUT AND SIGN AUTHORIZATION LETTER AT THE BACK HEREOF.
SURNAME
NAME
FIRST NAME EXTENSION
(e.g. Jr., Sr.)
MIDDLE NAME
MOTHER'S MAIDEN NAME

Preferred Login Name
(NMT 10 characters) EMAIL ADDRESS
DATE OF BIRTH MOBILE NO.

(mm / dd / yyyy)
RESIDENTIAL
SEX  Male  Female ADDRESS
 Single  Widowed
CIVIL STATUS  Married  Separated ZIPCODE
 Annulled Others, TEL. NO.
TEL. NO. FAX NO.
 Physician HOSPITAL / CLINIC
PROFESSION  Veterinarian
 Dentist ADDRESS
SPECIALIZATION / DEPARTMENT
(for Physicians only) ZIPCODE
SECTOR  Government  Private TEL. NO. FAX NO.

PRESENT ORIGINAL DOCUMENTS FOR VALIDATION AND SUBMIT CLEAR PHOTOCOPY
S2 ID CARD / CERTIFICATE 1a TIN ID CARD / LATEST ITR / BIR TIN 4a
1a. S2 License No. 4 VERIFICATION SLIP / e -TIN
1b. Date Issued 4a. TIN (one time submission)
1b 4b
1c. Valid Until 4b. Date Issued
1 FOR LOST OF VALID 1c DRUG TEST - DOH-DDB IDTOMIS 5a

S2 ID CARD /
GENERATED REPORT
CERTIFICATE : Submit
AFFIDAVIT OF LOSS AND 5b
5a. Drug Test Result
POLICE BLOTTER
PRC ID CARD 2a 5b. Date Issued 5c
2a. PRC License #
2b. Date Issued 2b 5c. Name of DOH Accredited Drug Testing
2 2c. Validity
5 Center
Note: Validity of S2 License 2c 5d
5d. Address
is harmonized with the PRC
ID Card Validity
PTR 3a 1 pc 2" x 2" ID picture with
3a. PTR O.R. # white background taken not
3b. Date Issued 3b
3 6 later than 6 months from
application, without eyeglasses
ID PICTURE
2X2
FOR GOVERNMENT MEDICAL PRACTITIONERS: Submit CERTIFICATE OF EMPLOYMENT in lieu of PTR
and original NOTARIZED AFFIDAVIT attesting that S2 license shall be used exclusively for government
practice only. Government practitioners are exempted from registration fee.
I SOLEMNLY SWEAR that the statements made on this Application Form are true and the attached supporting documents are authentic. It is
understood that I am bound to comply with the provision of RA 9165, otherwise known as the, “Comprehensive Dangerous Drugs Act of 2002,” and other
pertinent rules and regulations implemented by the Philippine Drug Enforcement Agency.
__________________________________
Printed Name and Signature of Applicant
PROCESSED BY: APPROVED BY:
________________________________________________ ________________________________________________
Signature Over Printed Name Director, Compliance Service
FM-CSVlrd-01 (page 2 of 2)
AUTHORIZATION
Date :
Director General
Philippine Drug Enforcement Agency
NIA Northside Road, National Government Center,
Brgy. Pinyahan, Quezon City
Attention: Director, Compliance Service
Dear Sir/Ma’am,
I hereby authorize the bearer whose signature and/or right thumb mark
appear below, to apply for and in my behalf:
[ ] S2 license renewal / [ ] S2 license re-application due to lost S2
for the period covering date of expiration / lost of my S2 license until (expiry of current
PRC license), for which I have filled-out the application at the reverse side.
____________________________________ ____________________________________
Signature of Authorized Representative Signature of Applicant
___________________________________ ____________________________________
Printed Name of Authorized Representative Printed Name of Applicant
Right thumb mark of

representative
REMINDERS
 NEW APPLICANT IS REQUIRED TO APPLY IN PERSON AT THE PDEA COMPLIANCE SERVICE / REGIONAL
COMPLIANCE SECTION.
 UNLESS SURRENDERED, SUSPENDED OR REVOKED LICENSE SHALL BE RENEWED ON OR BEFORE
EXPIRATION DATE AFTER RENEWAL OF LICENSE FROM PRC. BRING ORIGINAL AND PHOTOCOPY OF
OFFICIAL RECEIPT (O.R.) AND CLAIM SLIP.
 A SURCHARGE OF PHP 500.00 PER YEAR WILL BE IMPOSED FOR NON-RENEWAL OF LICENSE.
 NOTIFY PDEA IN WRITING AT LEAST 60 DAYS IN ADVANCE FOR AN INTENTION TO DISCONTINUE/RETIRE
THE S2 LICENSE AUTHORITY GRANTED.
 WRITTEN NOTIFICATION ON LOSS OF LICENSE WITHIN 48 HOURS FROM OCCURRENCE TO PDEA
COMPLIANCE SERVICE/REGIONAL COMPLIANCE SECTION. ADDITIONALLY SUBMIT NOTARIZED AFFIDAVIT
OF LOSS AND POLICE BLOTTER.
 RE-APPLICATION FOR A NEW LICENSE AND PAYMENT OF CORRESPONDING FEES.
 A DANGEROUS DRUG PREPARATION IS PRESCRIBED IN A SPECIAL PRESCRIPTION FORM FOR DANGEROUS
DRUGS WITH S2 LICENSE INDICATED THEREIN UNLESS OTHERWISE EXEMPTED BY A REGULATION.

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Republic of the Philippine FM-CSVlrd-01 (page 1 of 2)

Office of the President

S2 APPLICATION FORM FOR REGISTRATION OF MEDICAL PRACTITIONERS

MOTHER'S MAIDEN NAME

DATE OF BIRTH MOBILE NO.

SECTOR  Government  Private TEL. NO. FAX NO.

1 FOR LOST OF VALID 1c DRUG TEST - DOH-DDB IDTOMIS 5a

PROCESSED BY: APPROVED BY:

Attention: Director, Compliance Service

appear below, to apply for and in my behalf:

[ ] S2 license renewal / [ ] S2 license re-application due to lost S2

Right thumb mark of

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