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PRC Application Form Template

This document contains an application form for a Certificate of Authority to Operate Chemical Laboratories. It requests information about the applicant such as the name, address, contact details, type of business, and nature of operations. It also requires a list of safety equipment and devices, employment details of chemists and technicians, and an acknowledgement of the application. The process for application involves verification of documents, inspection of the laboratory, and approval or disapproval by the Board of Chemistry. A checklist of requirements is also provided.

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Gail Margarette Reyes
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© © All Rights Reserved
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Download as DOC, PDF, TXT or read online on Scribd
648 views

PRC Application Form Template

This document contains an application form for a Certificate of Authority to Operate Chemical Laboratories. It requests information about the applicant such as the name, address, contact details, type of business, and nature of operations. It also requires a list of safety equipment and devices, employment details of chemists and technicians, and an acknowledgement of the application. The process for application involves verification of documents, inspection of the laboratory, and approval or disapproval by the Board of Chemistry. A checklist of requirements is also provided.

Uploaded by

Gail Margarette Reyes
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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ANNEX”A”

Professional Regulation Commission


APPLICATION FORM
CERTIFICATE OF AUTHORITY TO OPERATE CHEMICAL LABORATORIES

Initial RenewalDate Filed:


Reference No:_________________
Part I General Information:
Name of Chemical Laboratory:
Address:
Name of the President/General Manager/Corporate Manager:
Contact Person: Contact Number: E-mail Adress:
Type of Business:

Corporation Partnership Sole Proprietorship Government Institution


Nature of Business

Chemical Laboratory Chemical Research Laboratory Chemical Supplier/Distributor

Quality Control Laboratory Chemical Teaching Laboratory

Testing Laboratory Chemistry Store/Stockroom


List of safety devices, facilities, laboratory furniture, glassware, utilities, equipment and ancillaries used in the chemical laboratory or
related establishment (use separate sheet it necessary):
1.
1.Do you have Safety Manual? Yes No

2. Do you provide Hazard Pay for Chemists and Laboratory Technicians?


Yes No

3.Do you provide Health Insurance for Chemists and laboratory Technicians? Yes No
List of the Employed Chemist/s and Chemical Technician/s (use separate sheet, it necessary):
CHEMISTS:

NAMESREGISTRATION NO. POSITION IN THE COMPANY SCOPE OF WORK

CHEMICAL TECHNICIANS:

NAMESREGISTRATION NO. POSITION IN THE COMPANY SCOPE OF WORK

_________________________________ _____________________ ____________________________ ________________________________


_________________________________ ______________________ ____________________________ ________________________________
_________________________________ ______________________ ____________________________ ________________________________
_________________________________ ______________________ ____________________________ ________________________________
_________________________________ ______________________ ____________________________
________________________________

Part II Acknowledgement:
I HEREBY CERTIFY that the above information written by me SUBCRIBED AND SWORN to before me this _____________ day
are true and correct to the best of my knowledge and belief. I of _____________ 20 ____ at _________________, affiant
further authorize PRC and other agencies to investigate the Applicant exhibited to me his/her valid government issued ID
authenticityof all the documents presented. _______________ issued at ______________ on
________________.
______________________ ___________________________
Signature of Applicant Date (Notary Public)
Part III Action Taken:
Registration Division: Legal Division:
(Verification of Licenses) (Clearance of no derogatory record)

Cash Division: Standards & Inspection Division:


Amount: ________________________________
O.R. No. ________________________________ Process by:
Date ________________________________ ____________________________
Issued by: ________________________________ Date: ____________________________
Reviewed by:
ATTY. MARIA LIZA M. HERNANDEZ
OIC, Standards & Inspection Division

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ACTION BY THE BOARD OF CHEMISTRY

INSPECTION OF THE APPLICANT’S CHEMICAL LABORATORY OR ESTABLISHMENT

DATE OF THE INSPECTION:____________________________________

FINDINGS:
___________________________________________________________________________________
_____
___________________________________________________________________________________
_____
___________________________________________________________________________________
_____
________________________________________________________________________________
________________________________________________________________________________

Approved Disapproved

______________________
Chairperson

_______________________ _______________________
Member Member

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PROCEDURE FOR THE ISSUANCE OF THE AUTHORITY TO OPERATE CHEMICAL
LABORATORIES OR RELATED ESTABLISHMENTS
(Window 5)
Step 2. Fill-out Application Form
Step 3. Proceed to Standards & Inspection Division processing window for evaluation
and assessment.
Step 4 Proceed to Registration Division for verification of License and Legal and
Investigation Division for notarization of application and to secure clearance of no
derogatory record.
Step 5. Proceed to cashier to pay the processing fee of P4,500.00 and Inspection Fee of
P2,000.00
Step 6. Submit Application Form with all the required documents and official receipt to the
Standards and Inspection Division designated window.
Step 7. Notice of Inspection will be issued at least two (2) week before the conduct of the
inspection.
Step 8. Verify the status of application after _____ days from the termination of
inspection. You may contact us at310-1048.

CHECKLIST OF REQUIREMENTS

[] Duly accomplished Application Form (Please notarized and affix documentary


stamp);
[ ] Authenticated copy of Certificate of Registration, Articles of Incorporation/Partnership
and By Laws issued by the Securities and Exchange Commission (SEC) for
corporation or partnership; or authenticated copy of Certificate of Registration from
Department of Trade and Industries (DTI) for sole proprietorship;
[ ] Pictures of the storage area or room where hazardous, toxic, and flammable
chemicals are stored;
[ ] Picture of the entire laboratory;
[ ] Valid Professional Identification Cards (PICs) of the Chemists and Registered
Chemical Technicians employed
[ ] Payment of accreditation fee and Inspection Fee (In Cash, Postal Money Order,
Manager’s Check or Bank Draft payable to the Professional Regulation Commission)
[ ] Short Brown Envelope for the Certificate of Accreditation;
[ ] Set of documentary stamps.

Note:

1. Applications with incomplete documents will not be accepted. Documentary stamps


are available at the PRC costumer service counters and PRC Regional Offices.
2. Representative/s filing and claiming the Certificate of Authority to Operate Chemical
Laboratory or related Entity on behalf of the applicant must present Special Power of
Attorney (SPA) and valid proof of identification.

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