Post Travel Report

Note: All fields are required.

License to Operate Number: Indicate the correct License-to-Operate (LTO) Number issued by the FDA.
Name of Establishment: Indicate the registered name of establishment corresponding to the issued LTO.
Medical Director: Indicate the full name (First Name, Middle Initial, Last Name) of the establishment's Medical Director or its equivalent as notified to the FDA.
Landline Number: Indicate landline number of the establishment.
Mobile Number: Indicate mobile number of the establishment, if any.
E-mail Address: Indicate email address of the establishment.
Date From: Indicate date (month, day, year) of departure.
Date To: Indicate date (month, day, year) of return.
Type of Travel: Local International Indicate if venue is within the Philippines (Local) or is outside Philippines (International).
Address of Venue: Indicate correct name of hotel/venue with correct and complete address.
Title of the Event: Indicate the complete title of the event/symposium/congress/training/seminar.
Objective/s of the Event: Indicate the objective/s of the sponsored event.
Relevance/Impact to the Philippine Situation: Relate the relevance/impact of attending to the sponsored event to healthcare practice and Philippine situation in general.

Delegate Details
Name of Delegate Office Position Association/Society Contact Information

Commitment Details
Commitment of the Delegate/s
as part of the Sponsorship
Specific Activites Timelines

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