Page 1 Form HOS-LTO-AF-2007 Page 1 of 5 APPLICATION FOR LICENSE TO OPERATE A HOSPITAL OR OTHER HEALTH FACILITY Date: ______________ The

Director Bureau of Health Facilities and Services Department of Health Manila Sir/Madam: Pursuant to Section 9 of R.A. 4226 Hospital Licensure Act, I hereby apply for a: [ ] Registration and Initial License to Operate a hospital or other health facility [ ] Renewal of License to Operate a hospital or other health facility In this regard, I am submitting the following information: Name of Hospital/Health Facility : Complete Address No. : Street Barangay City/Municipality Province Region Telephone and/or Fax Number

: Owner : Chief of Hospital/Medical Director : Chairman of the Board (If Corporation) : Authorized Bed Capacity : Classification : Function [ ] General [ ] Special Ownership [ ] Government [ ] Private Service Capability [ ] Level 1 Hospital [ ] Level 2 Hospital [ ] Level 3 Hospital [ ] Level 4 Hospital [ ] Birthing Home [ ] Acute Chronic Psychiatric Care Facility [ ] Custodial Psychiatric Care Facility ________________________________________ Page 2

Form HOS-LTO-AF-2007 Page 2 of 5 Attached are the following documents: For Initial For Renewal 1. Notarized Application for License To Operate A Hospital or Other Health Facility (this form) 2. Letter of Endorsement to the Director of the Bureau of Health Facilities and Services (if filed at CHD) 3. List of Personnel (use attached form) 4. List of Equipment/Instrument (use attached form) 5. Duly accomplished Assessment Tool (use attached form) 6. Photographs of the Exterior and Interior of the Hospital/Health Facility 7. Location Map 8. Annual Hospital/Health Facility Statistical Report Items shaded are NOT required. Very truly yours, _____________________________ Signature Above Printed Name _____________________________ Position ________________________________________

Page 3 Form HOS-LTO-AF-2007 Page 3 of 5 LIST OF PERSONNEL Name of Hospital/Health Facility : Address of Hospital/Health Facility : Fill up all items by writing down the answer and/or putting a check on the appropriate boxes. STATUS NAME POSITION PRC No. P e rm a n e n t T e m p

o ra ry C a s u a l TRAINING SIGNATURE Use additional sheets when necessary Prepared by : ________________________________________ Page 4 Form HOS-LTO-AF-2007 Page 4 of 5 LIST OF EQUIPMENT/INSTRUMENT Name of Hospital/Health Facility : Address of Hospital/Health Facility : Fill up all items by writing down the answer and/or putting a check on the appropriate boxes. CONDITION ITEM DATE

ACQUIRED QTY New Serviceable NonServiceable REMARKS Use additional sheets when necessary. Prepared by : ________________________________________ Page 5 Form HOS-LTO-AF-2007 Page 5 of 5 Name Designation Civil Status Home Address Acknowledgement Republic of the Philippines ) City/Municipality of _______________ ) S. S. I, ____________________________, ____________________________, of legal age, ______________, a resident of __________________________________________________, after having been sworn in accordance with law hereby depose and say that I am executing this

affidavit to attest to the completeness and truth of the foregoing information and the attached documents required for the registration and initial/ renewal of license to operate a hospital or other health facility pursuant to Section 9 of R.A. 4226 Hospital Licensure Act. _____________________________ Signature Before me, this _______ day of ______________ 2007 in the City/ Municipality of _____________________, Philippines, personally appeared the above affiant with Community Tax Certificate No. _____________________ issued on _____________________ at _____________________, known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is their free act and deed. IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 2007. NOTARY PUBLIC My Commission Expires December 31, 20______ Doc. No. _________ ; Page No. _________; Book No. _________ ; Series of 20 _______