PLEASE PRINT CLEARLY. USE A BLACK BALLPEN . ALL THREE (3) COPIES MUST BE LEGIBLE.

NOT FOR SALE

NFA FORM NO. ISD-IRD 057-AB/2009

TO BE FILLED OUT BY NFA
DATE FILED NATIONAL FOOD AUTHORITY RETAILING
DAY MONTH YEAR
APPLICATION FOR LICENSE FOR: WHOLESALING
PLACE OF FILING CURRENT YEAR 2ND YEAR 3RD YEAR RETAILING & WHOLESALING
CONTROL NO. 1 NEW 3 ADDITIONAL BUSINESS LINES COMBINED
RURBAN CODE
2 RENEWAL 4 ADDITIONAL STORE ANNEX A & B
TIN NO. APPLICANT'S LAST NAME GIVEN NAME MIDDLE NAME

REGISTERED BUSINESS TRADE NAME PRINCIPAL PLACE OF BUSINESS (NO. & STREET, TOWN / CITY, PROVINCE)

RETAILING
() MAIN OR
STORE BRANCH RURBAN CODE RICE / CORN / OTHERS (TO BE FILLED OUT BY NFA)
LOCATION
NO. (TO BE FILLED BY NFA) CAPITALIZATION LICENSE PLATE NO. / STICKER NO.
M B

1
P
2

WHOLESALING
() MAIN OR
STORE BRANCH RURBAN CODE RICE / CORN / OTHERS (TO BE FILLED OUT BY NFA)
LOCATION
NO. (TO BE FILLED BY NFA) CAPITALIZATION LICENSE PLATE NO. / STICKER NO.
M B

1
P
2

RETAILING & WHOLESALING COMBINED

() MAIN OR
STORE BRANCH RURBAN CODE RICE / CORN / OTHERS CAPITALIZATION (TO BE FILLED OUT BY NFA)
LOCATION
NO. (TO BE FILLED BY NFA) LICENSE PLATE NO. / STICKER NO.
M B RETAILING WHOLESALING

1
P P
2

LICENSE FEE
RETAILING & _______________________________________________________
RETAILING WHOLESALING WHOLESALING SIGNATURE OVER PRINTED NAME OF THE APPLICANT /
AUTHORIZED REPRESENTATIVE
COMBINED
P P P REMARKS / RECOMMENDATIONS (TO BE FILLED OUT BY NFA)
O.R. NO. O.R. NO. O.R. NO.

O.R. DATE O.R. DATE O.R. DATE

DATED PROCESSED BY: PROV'L. RLO PROV'L. MGR./OIC

DATE APPROVED
DAY MONTH YEAR
DAY MO. YR.
DAY MONTH YEAR REVIEWED BY: REG'L. RLO