Email Worksheet

The application form has six parts: 1) General RAMON MAZA SR. MEMORIAL DISTRICT
Information, 2) Establishment Information, 3) Product SUBJECT:
HOSPITAL#VI
Information, 4) Supporting Information, 5) Sources and
Clients, and 6) Applicant Information. In the worksheet
'Form' (with the red tab) you will see a dashboard BEGIN:LTO;CDRR;RAMON MAZA SR.
where the different parts are identified. If the part is MEMORIAL DISTRICT
appropriately filled up, a green 'PROCEED' will be HOSPITAL#VI#Retailer#0;VAR#0#0#0#0#0#
indicated.Required fields will appear sequentially.To BODY: MiV-Transfer of Location of Offices#MiV-
minimize errors and confusion, it is recommended that Transfer of Location of Offices#MiV-Transfer
a blank form be used for every application. If the form of Location of
is appropriately filled up, the composed body text (in Offices#0;3500;50;7200;10750:END
the green box) will appear.
Be careful to paste the body text completely as text
(not as an image or as an attachment). DON'T attach
any file to the email request. Printing Instructions
(Please print the following parts of the worksheet 'Form
For Drug Registration (excluding amendmen
For Non-Drug Registration (excluding amendmen
For Licensing (exclusing amendmen
For A

Application Process Overview

Application form is Download

The integrated application form in XLS or XLSX forma
Registration applications, as well as amendments and
downloaded from and advertisements are also now covered in the appli
www.fda.gov.ph valid LTO is required for a C

Fill Up Form
The application form has six parts: 1) General Info
Application form is filled up Information, 3) Product Information, 4) Supporting
Clients, and 6) Applicant Information. If the part is ap
correctly 'PROCEED' will be indicated.Required fields will appe
appropriately filled up, the composed body text (in
Application form is filled up Information, 3) Product Information, 4) Supporting
Clients, and 6) Applicant Information. If the part is ap
correctly 'PROCEED' will be indicated.Required fields will appe
appropriately filled up, the composed body text (in

Send an email to
Email
In the XLS application form, the worksheet 'Email' com
the email that should be sent to [email protected]. Co
fields onto the email. Include CCs as needed. The XL
[email protected] attached but it will be required during submission.
rejection of schedule request. Up to ten applications in

Within two working days, a

Document Tracking Log
Scheduling
The FDA will determine the schedule of applications a
Centers. A quota will be set for the total number o
scheduled in a day. Multiple applications sent in a sin
(DTL) is sent with a over separate days. Requests for specific schedules
schedule for submission Receiving will be scheduled within 10 working days of

Fees are paid either at Land Pay

Once a DTL is received, payment can be made immed
the Land Bank of the Philippines, The main FDA cashie
scheduled to be received for the day. A copy of the DT
Bank branches or at the of the application form are required to process payme
main FDA cashier form the tracking number provided. Check that the tra
DTL is indicated in the proof of p
Fees are paid either at Land the Land Bank of the Philippines, The main FDA cashie
scheduled to be received for the day. A copy of the DT
Bank branches or at the of the application form are required to process payme
main FDA cashier form the tracking number provided. Check that the tra
DTL is indicated in the proof of p

Check if all requirements

Check
Be sure that you have a checklist of requirements and
documents. Don't forget to have the petition or de
softcopy of all requirements should be stored in a US
are in order Include an XLS or XLSX copy of the accomplished appl
USB devices free of malicious software. A copy of th
required at the point of subm

Submission
Only applications scheduled for the day will be accom
Application is filed in on longer be required at submission. Don't forget to get
transfer documents. Remember the RSN number of ea
schedule follow-up through [email protected]. Should you fail to
set date, queue for another schedule through pair@
MORIAL DISTRICT IMPORTANT

READ THIS PAGE CAREFULLY.

ON MAZA SR.
Provide information only
#0;VAR#0#0#0#0#0# when asked for.
on of Offices#MiV-
f Offices#MiV-Transfer

0;10750:END

of the worksheet 'Form' if applicable)

on (excluding amendments and compliances): pages 1 and 4.
on (excluding amendments and compliances): pages 1 and 3.
ng (exclusing amendments and compliances): pages 1 and 2.
For All Other Applications: page 1 only.

d
m in XLS or XLSX format is used for both License and
ell as amendments and other certifications. Promos
w covered in the application form. Remember that a
LTO is required for a CPR.

m
x parts: 1) General Information, 2) Establishment
mation, 4) Supporting Information, 5) Sources and
mation. If the part is appropriately filled up, a green
equired fields will appear sequentially. If the form is
omposed body text (in the green box) will appear.
mation, 4) Supporting Information, 5) Sources and
mation. If the part is appropriately filled up, a green
equired fields will appear sequentially. If the form is
omposed body text (in the green box) will appear.

worksheet 'Email' composes the subject and body of

o [email protected]. Copy and paste the appropriate
CCs as needed. The XLS or XLSX file should not be
ed during submission. Any attachment will lead to
p to ten applications in a single email are acceptable.

g
edule of applications according to the priority of the
for the total number of applications that can be
pplications sent in a single email may be scheduled
for specific schedules will not be accommodated.
hin 10 working days of receipt of application email.

nt can be made immediately through any branch of

, The main FDA cashier will only accommodate those
e day. A copy of the DTL provided by FDA and a copy
uired to process payment. Indicate in the application
ded. Check that the tracking number indicated in the
cated in the proof of payment.
 , The main FDA cashier will only accommodate those
e day. A copy of the DTL provided by FDA and a copy
uired to process payment. Indicate in the application
ded. Check that the tracking number indicated in the
cated in the proof of payment.

t of requirements and that you have all the necessary

have the petition or declaration form notarized. A
hould be stored in a USB device to facilitate transfer.
he accomplished application form. Please keep your
software. A copy of the OnColl Payment Slip is also
d at the point of submission.

n
r the day will be accommodated. Hard copies will no
on. Don't forget to get back the USB devices used to
the RSN number of each application. Use the RSN to
v.ph. Should you fail to complete submission on the
schedule through [email protected] using the RSN.
 APPLICATION FORM 5 SOURCES & CLIENTS PROCEED

This is the application form. Without the

appropriate petition or declaration form, this
application may be rejected.
Document Tracking Number APPLICATION FORM STATUS
GENERAL INFORMATION: PROCEED
ESTABLISHMENT INFORMATION: PROCEED
Description (Optional): PRODUCT INFORMATION: PROCEED
SUPPORTING INFORMATION: PROCEED
1 GENERAL INFORMATION PROCEED SOURCES & CLIENTS: PROCEED
1.1 Product Center: Drug
APPLICANT INFORMATION: PROCEED
ORDER OF PAYMENT
1.2 Authorization: License to Operate
Amount Due: Php 10,750.00
Fee : Php 3,500.00
Legal Research Fee : Php 50.00
1.3 Type: Variation
Surcharge : Php 7,200.00
OR Number :
1.4 Primary Activity: Retailer
Date Paid:
Computation Valid Until: 31 March, 2023
TURNED INITIAL This form was last edited on 13 October 2016, 10:28 AM.

06-0002-21-H1-1
PROCEED
31-Dec-22

Yes

Minor

Transfer of Location of Offices

Minor

Transfer of Location of Offices

Minor

Transfer of Location of Offices

2 ESTABLISHMENT INFORMATION PROCEED

2.1 Name of Establishment
RAMON MAZA SR. MEMORIAL DISTRICT HOSPITAL

2.3 Tax Identification Number: 000-578-321-000

2.4 Office Address 2.5.1 Region: VI
CATUNGAN I, SIBALOM, ANTIQUE

6 APPLICANT INFORMATION PROCEED

The undersigned attest to have provided true and complete information in this form, and to provide complete
requirements at the time of submission. The undersigned agree to strict compliance with the rules and regulations of
2.7.0 E-mail Address: [email protected] the Food and Drug Administration (FDA), including Good Manufacturing Practice (GMP), Good Distribution and Storage
2.7.1 Contact Detail 1 Mobile: 9177056295 Practice (GDSP), Good Pharmacy Practice (GPP), and/or Good Laboratory Practice (GLP). Further, the undersigned agree
to grant authority to the FDA to verify the truthfulness of the information provided with this application.
2.7.2 Contact Detail 2 Mobile: 9173017095
2.7.3 Contact Detail 3 Mobile: 9060440567
6.1 APPROVING AUTHORITY
Signature 6.1.5 Mailing Address
RAMON MAZA SR. MEMORIAL
PROCEED DISTRICT HOSPITAL DISTRICT II,
SIBALOM, ANTIQUE
6.1.1.0 Family
Latest photo of applicant
Name: JARDENIL
6.1.1.1 First
GILFRED
Name(s): 6.1.6.0 E-mail Address:
6.1.1.2 Middle [email protected]
MAHINAY
Name: 6.1.6.1 Contact Detail 1
6.1.2 Designation: Owner/ General Manager/ President Mobile: #FMT
6.1.3 Tax ID Number: 123-733-909 6.1.6.2 Contact Detail 2
6.1.4.0 Type of Gov't ID: Professional Regulatory Commission Mobile: #FMT
6.1.4.1 ID Number: 60500 6.1.6.3 Contact Detail 3
6.1.4.2 Date Expiry: 27-Nov-24 Mobile: #FMT
6.2 APPLICANT
Signature 6.2.5 Mailing Address
RAMON MAZA SR. MEMORIAL
DISTRICT HOSPITAL DISTRICT II,
SIBALOM, ANTIQUE
6.2.2.0 Family
Latest photo of applicant
Name: BERTOLANO
6.2.2.1 First
ROSEBELLE
Name(s): 6.2.6.0 E-mail Address:
6.2.2.2 Middle [email protected]
GENTELIZO
Name: 6.2.6.1 Contact Detail 1
6.2.2 Designation: Company Pharmacist Mobile: #FMT
6.2.3 Tax ID Number: 946-365-515 6.2.6.2 Contact Detail 2
6.2.4.0 Type of Gov't ID: Professional Regulatory Commission Mobile: 9173017095
6.2.4.1 ID Number: 49769 6.2.6.3 Contact Detail 3
6.2.4.2 Date Expiry: 10-Sep-24 Mobile: #FMT
License to Operate

This is the petition form for establishment licensing by the Food and Drug Administration of the Philippines.
 PETITION
We categorically declare that all data and information submitted in connection with this application as well as other submissions in the future including
amendments, are true, correct, and reflect the total information available.
I/we am/are duly authorized to affirm the following declaration on behalf of the Company: RAMON MAZA SR. MEMORIAL DISTRICT HOSPITAL

I. The said establishment shall be open for business hours under the supervision of a PRC registered professional (if applicable) or authorized personnel;

II. The pharmacist and other allied health professionals, upon and during employment in this establishment, is/are not and will not in any way be connected with any
other FDA-regulated establishment (if applicable);

III. The approved and valid License to Operate shall be displayed in a conspicuous place of the establishment;

IV. To change the business name of the establishment and/or brand name of products in the event that there is a similar or same name registered with the Food and
Drug Administration, or if the FDA rules later that it is misleading;

V. The attached electronic copy of files/documents/information of the LTO application are the exact duplicate of the hard copy and, any discrepancy, prejudicial
contents or willful misrepresentation on any of the data therein shall be a ground for disapproval of application and/or the filing of legal action against the
undersigned and/or the company;

VI. If applying for automatic renewal:

a. Have filed the application, and have paid the complete & appropriate renewal fee before expiry date;

B. That there are no changes or variations in the establishment since the last renewal of LTO specifically but not limited to change of location, change of
ownership, change of business name, change of registered pharmacist, change in warehouse site, additional supplier and product lines, change in activity, change
in key personnel;

VII. The products we manufacture, distribute and/or sell are registered or to be registered with FDA prior to distribution or sale, and that we assume primary
responsibility and/or stewardship over the product in case of liability, adverse events, and/or other public health & safety issues;

VIII. The establishment whether for initial, renewal or automatic renewal, is still subject to inspection by FDA’s authorized representatives at any reasonable time
and undertake to respond and cooperate fully with the FDA with regard to any subsequent post-marketing activity;

IX. Non-compliance with the requirements and/or failure to give notice to the FDA of the change in business address, business name, ownership, or any other
circumstances in relation to the approval of this application is a ground for revocation of the License to Operate;

X. Any violation of the above provisions and rules and regulations will automatically be subject to the SUSPENSION/ CANCELLATION/ REVOCATION of the License to
Operate.

XI. I/We make this declaration in full knowledge and awareness of Republic Act No. 3720, as amended by Republic Act no. 9711, otherwise known as the Food and
Drug Administration Act of 2009, other allied laws and their implementing rules and regulations.

WHEREFORE, the undersigned confirm the truth of our declaration and awareness of the foregoing duties and responsibilities among others, and prays that this
application for License to Operate be granted after compliance with the Food and Drug Administration’s requirements.

WAIVER
I HEREBY GRANT AUTHORITY TO THE FOOD AND DRUG ADMINISTRATION TO VERIFY THROUGH BOTH GOVERNMENT AND PRIVATE
RESOURCES THE AUTHENTICITY OF ALL THE INFORMATION AND DOCUMENTS SUBMITTED .

ACKNOWLEDGEMENT
SUBSCRIBED AND SWORN TO BEFORE ME this _______ day of _________________ 20________ at ______________________________

_______________________________________________________, Philippines, personally appeared the following :

Name and Signature Identification Number Expiry Date of ID Place Issued

Professional Regulatory
27-Nov-24
Commission:60500
1) GILFRED MAHINAY JARDENIL ______________________________
Professional Regulatory
10-Sep-24
Commission:49769
2) ROSEBELLE GENTELIZO BERTOLANO ______________________________
Known to me and to me known to be the same persons who execute the application form and this petition form, and they acknowledged to me that the same is
their free and voluntary act and deed. WITNESS MY HAND AND SEAL on the date and place first above written.

Doc. No. : _____________________________

Page No. : ____________________________
Book No. : ____________________________
Series of : _____________________________
 Provide in this space a description of the
product in terms of rheology, thermal, and
Off-white to beige, semi biconvex film- Use this space to explain how the lot code
geometry properties among others, as
CLOPIDOGREL (as BISULFATE) coated tablet with score on one side and used on the product label is correctly
applicable; Indicate if appropriate
plain on the other side interpreted
microbiological cultures present in the
product
CLOPIDOGREL (AS BISULFATE) NINBO BEITONG IMP. & EXP. CO. LTD., INDIA KAMAGONG CHEMTRADE CORP./SAN PEDRO LAGUNA
2) Active Pharmaceutical Ingredient; 2) API Manufacturer, Address Address Address; 2) API Supplier, Address Address Address;
3) Active Pharmaceutical Ingredient; 3) API Manufacturer, Address Address Address; 3) API Supplier, Address Address Address;
4) Active Pharmaceutical Ingredient; 4) API Manufacturer, Address Address Address; 4) API Supplier, Address Address Address;
5) Active Pharmaceutical Ingredient; 5) API Manufacturer, Address Address Address; 5) API Supplier, Address Address Address;
6) Active Pharmaceutical Ingredient; 6) API Manufacturer, Address Address Address; 6) API Supplier, Address Address Address;
7) Active Pharmaceutical Ingredient; 7) API Manufacturer, Address Address Address; 7) API Supplier, Address Address Address;
8) Active Pharmaceutical Ingredient; 8) API Manufacturer, Address Address Address; 8) API Supplier, Address Address Address;
9) Active Pharmaceutical Ingredient; 9) API Manufacturer, Address Address Address; 9) API Supplier, Address Address Address;
10) Active Pharmaceutical Ingredient; 10) API Manufacturer, Address Address Address; 10) API Supplier, Address Address Address;
11) Active Pharmaceutical Ingredient; 11) API Manufacturer, Address Address Address; 11) API Supplier, Address Address Address;
12) Active Pharmaceutical Ingredient; 12) API Manufacturer, Address Address Address; 12) API Supplier, Address Address Address;
 Department of Health
Food and Drug Administration
APPLICATION FORM STATUS: APPLICATION FORM 1
GENERAL INFORMATION: PRO 1 1 0 0 0 0 0 SOURCES & CLIENTS: PRO 1 1 0 1
ESTABLISHMENT INFORMATION: PRO 1 0 0 1 1 Document Tracking Number 1 1
PRODUCT INFORMATION: PRO 1 0 0 0 1 0 0 1 1
SUPPORTING INFORMATION: PRO 1 1 0 0 0 0 0 1 1 1 1
APPLICANT INFORMATION: PRO 1 1 1 1 Description (Optional):
PAYMENT INFORMATION: 1 0 0
GENERAL INFORMATION 2 ESTABLISHMENT INFORMATION 1 1

1.1 Product Center: Drug 1.4 Primary Activity: Retailer

2.1 Name of Establishment 1 1
1.2 Authorization: License to Operate
RAMON MAZA SR. MEMORIAL DISTRICT HOSPITAL
1.3 Type: Variation 1 1 1
2.3 Tax Identification Number: 000-578-321-000
TURNED INITIAL 2.4 Office Address 2.5.1 RegioVI
1 1
0 CATUNGAN I, SIBALOM, ANTIQUE
30-Dec-1899 1
1 1
1
1
0 1 1
30-Dec-1899 1
2.7.0 E-mail Address: [email protected]
2.7.1 Contact Detail 1 Mobile: 9177056295 1 1
0 2.7.2 Contact Detail 2 Mobile: 9173017095
0 0 2.7.3 Contact Detail 3 Mobile: 9060440567
1 1
1

0 1 1 1
0
1 1 1
Drug 1 0 HUHS 1 1
0 0 Food 0 Device 1 1
1 1
1 1 1
1 1
0 1 1 1
0 0
None 0 None 0
1 1

0 0
0 1 1
1 0
0
1 1 0 1 1
Type of Amendment: Other Amendments 0 0 1 1
Source: Add/ Delete FAL 0 License to Operate FAL 0 0 1 1
Source: Change of B FAL 0 Reclassification FAL 0 0 0 1 0 1
Change of Importer/ DFAL 0 0 Change of DistributorFAL 0 0 0 01 1 01 1
Product Registration FAL 0 Finished Product FAL 0 Php -
None 0 None 0
License to Operate FAL 0 Raw Material FAL 0
0 Free Sale, Certificate FAL 0 1 1 1
Pharmaceutical Produc FAL 0
Export Certificate FAL 0 0
Additional ProductionFAL 0 0 1 1 1
ORDER OF PAYMENT 1
Amount Due: 10750
Fee : 3500 1 1
Legal Research Fee : 50 1 1
Surcharge : 7200 1 1
OR Number : 0 1 0 1
Date Paid: This is the application form. Without the appropriate petition 01 1 01 1
Computation Valid Until: 45016 or declaration form, this application may be rejected.
None 0 None 0
6 APPLICANT INFORMATION
1 1

The undersigned attest to have provided true and complete information in this form, and to provide complete requirements
at the time of submission. The undersigned agree to strict compliance with the rules and regulations of the Food and Drug 1 1
Administration (FDA), including Good Manufacturing Practice (GMP), Good Distribution and Storage Practice (GDSP), Good
Pharmacy Practice (GPP), and/or Good Laboratory Practice (GLP). Further, the undersigned agree to grant authority to the
FDA to verify the truthfulness of the information provided with this application.

6.1 APPROVING AUTHORITY

6.1.5 Mailing Address 1 1
1 1
1 1
Signature 0 1 0 1
01 1 01 1
6.1.1.0 Family Na JARDENIL
None 0 None 0
RAMON MAZA SR. MEMORIAL DISTRICT HOSP
6.1.1.1 First NameGILFRED 6.1.6.0 E-mail Address: 1 1
[email protected]
Latest photo of applicant 6.1.1.2 Middle NaMAHINAY 6.1.6.1 Contact Detail 1
6.1.2 Designation: Owner/ General Manager/ President Mobile: #FMT 1 1
6.1.3 Tax ID Number: 123-733-909 6.1.6.2 Contact Detail 2
6.1.4.0 Type of Gov't ID: Professional Regulatory Commission Mobile: #FMT
6.1.4.1 ID Number: 60500 6.1.6.3 Contact Detail 3 1 1
6.1.4.2 Date Expiry: 27-Nov-24 Mobile: #FMT 1 1
6.2 APPLICANT 1 1
6.2.5 Mailing Address 0 1 0 1
01 1 01 1
None 0 None 0
Signature
1 1
6.2.2.0 Family Na BERTOLANO
RAMON MAZA SR. MEMORIAL DISTRICT HOSP
6.2.2.1 First NameROSEBELLE 6.2.6.0 E-mail Address: 1 1
[email protected]
Latest photo of applicant 6.2.2.2 Middle NaGENTELIZO 6.2.6.1 Contact Detail 1
6.2.2 Designation: Company Pharmacist Mobile: #FMT 1 1
6.2.3 Tax ID Number: 946-365-515 6.2.6.2 Contact Detail 2 1 1
6.2.4.0 Type of Gov't ID: Professional Regulatory Commission Mobile: 9173017095 1 1
6.2.4.1 ID Number: 49769 6.2.6.3 Contact Detail 3 0 1 0 1
6.2.4.2 Date Expiry: 10-Sep-24 Mobile: #FMT 01 1 01 1

Page 11 of 18 858909975.xlsx 03/05/2025 09:09:40

 Department of Health
Food and Drug Administration
License to Operate APPLICATION FORM
This form is the second page of a two-page application form for licensing by the Food and Drug Administration of the Philippines.

PETITION

I/we am/are duly authorized to affirm the following declaration on behalf of the Company:

I. The said establishment shall be open for business hours under the supervision of PRC registered professional (if applicable) or authorized personnel;

II. The pharmacist and other allied health professionals, upon and during employment in this establishment, is/are not and will not in any way be connected with any other FDA regulated establishment (if applicable);

III. The approved and valid License to Operate shall be displayed in a conspicuous place of the establishment;

IV. To change the business name of the establishment in the event that there is a similar or same name registered with the Food and Drug Administration or if it rules later that it is misleading;

V. The attached electronic copy of files/documents/information of the LTO application are the exact duplicate of the hard copy and, any discrepancy/ prejudicial contents or wilful misrepresentation on any of the data therein shall be a ground for disapprov

VI. If applying for automatic renewal:

a. Have filed the application before expiry date;

b. Have paid the renewal fee prior its expiry date;

c. That there are no unapproved changes or variations whatsoever in the establishment since the last renewal of LTO specifically but not limited to change of location, change of ownership, change of business name, change of registered pharmacist, cha

VII. The products we manufacture, distribute or sell are registered or to be registered with FDA prior to distribiution or selling;

VIII. The establishment whether for initial, renewal or automatic renewal, is still subject to inspection by FDA’s authorized representatives at any reasonable time and undertake to respond and cooperate fully with the FDA with regard to any subsequent p

IX. Non-compliance with the requirements and/or failure to give notice to the FDA of the change in business address, business name, ownership, or any other circumstances in relation to the approval of this application is a ground for delisting of the Licen

X. Any violation of the above provisions and rules and regulations will automatically be subject to the SUSPENSION/ CANCELLATION/ REVOCATION of the License to Operate.

XI. I/We make this declaration in full knowledge and awareness of Republic Act No. 3720, as amended by Republic Act no. 9711, otherwise known as the Food and Drug Administration Act of 2009, other allied laws and their implementing rules and regul

WHEREFORE, the undersigned confirm the truth of our declaration and awareness of the foregoing duties and responsibilities among others, and prays that this application for License to Operate be granted after compliance with the Food and Drug Admini

WAIVER

I HEREBY GRANT AUTHORITY TO THE FOOD AND DRUG ADMINISTRATION TO VERIFY THE AUTHENTICITY OF ALL THE DOCUMENTS SUBMITTED FROM BOTH GOVERNMENT AND PRIVATE RESOURCES.

ACKNOWLEDGEMENT

SUBSCRIBED AND SWORN TO BEFORE ME this _______ day of _________________ 20________ at ______________________________

_______________________________________________________, Philippines, personally appeared the following :

Name and Signature Identification Number Date Issued Place Issued

1) JARDENIL GILFRED _________________________ ___________ ______________________________

2) _________________________ ___________ ______________________________

Known to me and to me known to be the same persons who execute the foregoing instrument consisting of 2 pages including the application form, and they acknowledged to me that the same is their free and voluntary act and deed. WITNESS MY HAND

Doc. No. : _____________________________

Page No. : ____________________________

Book No. : ____________________________

Series of : _____________________________

Page 12 of 18 858909975.xlsx 03/05/2025 09:09:40

 Department of Health
Food and Drug Administration
APPLICATION FORM

Page 13 of 18 858909975.xlsx 03/05/2025 09:09:40

 Department of Health
Food and Drug Administration
APPLICATION FORM

Page 14 of 18 858909975.xlsx 03/05/2025 09:09:40

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 APPL OTHER REQUEST PAYMENT DETAILS
Shelf-StoraPackaSuggeNo. oExpirCPR VRegistrat RegisAmenAmenAmenCerti OtherFee LRF SurchTotalOR NDate Issued
0 0 0 ### 0 ### ### ### VAR MiV-TMiV-TMiV-Transfer o### ### ### ### ### ###