The Director Food and Drug Administration Civic Drive, Filinvest Corporate City, Alabang, Muntinlupa City Attention:

Product Services Division

Sir/Madam: In accordance with R.A. 9711 and other related issuances, we wish to apply for the registration of the following:

CATEGORY I CATEGORY II FOOD SUPPLEMENT

LOCAL IMPORTED

Name of Product*

Source of the Product Name of Name of Manufacturer Supplier

Food Registration Number (FR No.)

* Provide additional row/s if more than one product is applied.

Together with this application we are submitting the following: a. b. c. d. Valid License to Operate (LTO) Loose Label/s Sample of Product/s Original Certificate/s of Product Registration (CPR)

We categorically declare that all data and information submitted herewith are true and correct and any material misrepresentation or non-disclosure or omission of relevant information will render the application ineffective. We also declare that the product/s do not contain ingredients and additives that are not permitted for use in human food in accordance with relevant regulations. We understand and agree that the product/s may be subjected to FDA laboratory examination at any time to verify the products safety, quality and conformity with labeling claims and that the cost of said examination shall be at our expense. We also take full responsibility and accountability for the quality, safety and truth in the labeling declaration of the said food product/s. For the product/s whose registration is being renewed, we declare that, no material change in formulation, labeling and technical specification in the said product/s was made. Finally, we agree and bind ourselves that any material change in formulation, labeling, and technical specification in the product in the future will be duly communicated and cleared with the BFAD.

Date: _______________________ Company Name: ____________________________ By:

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Indicate Authority