Republic of the Philippines

Department of Health
Food and Drug Administration
CENTER FOR DEVICE REGULATION, RADIATION HEALTH, AND RESEARCH
(former name : Bureau of Health Devices and Technology)
LICENSING AND REGISTRATION DIVISION
CDRRHR-2-L-02D
Revision No. 2
Date Effective: 15 April 2015

JOINT AFFIDAVIT OF UNDERTAKING

JOINT AFFIDAVIT OF UNDERTAKING
______________________________ PHARMACIST-IN-CHARGE
(PRC Registered Name) With PRC Registration No. _______________
Issued on_______________________________
PTR NO. _______________________________
______________________________________
(Maiden or Maiden Name different from above)

of legal age, single/married, and a resident of __________________________________ and__________

_____________________________________________________________________________________
owner of____________________________________________________________________________
(Medical Device Establishment)
located at _______________________________________________________________ of legal age and
resident of_________________________________________________ after having been sworn in accordance
with law, hereby declare:

FIRST - That we are fully aware of the provisions of the Pharmacy Law, the Foods, Drugs, Devices, and
Cosmetics Act, the Generics Act of 1988, that we are aware of the specific requirements that the Operation
of______________________________________________________________________________shall be
under the IMMEDIATE AND PERSONAL SUPERVISION of the Pharmacist-In-Charge, the business hours
being from _______AM to ________ PM;

SECOND that we agree to change the business name if there is already a validly registered name similar to
our business name;

THIRD that we shall display our approved License to Operate (LTO) in a conspicuous place of our
establishments;

FOURTH - that we shall notify FDA in case of any change(s) in the circumstances of our application for a
License to Operate, including but not limited to change(s) of location, change of ownership, change of
pharmacist-in-charge, and change in medical device products;

FIFTH and that I, the pharmacist-in-charge, am not and will not be in any way connected with any drug or
similar establishment/outlet;

WE execute this Joint Affidavit of Undertaking to confirm the truth of our declaration and our awareness of the
fore going duties and responsibilities among others.

WITNESS WHEREOF, WE hereunto affix our signature this _________________day of _____________ 20

_______..
__________________________________
OWNER
Res. Cert. No. ______________________
Issued on __________________________
at _______________________________
___________________________________
PHARMACIST
Res. Cert. No. ________________________
Issued on ___________________________
at _________________________________

SUBSCRIBED AND SWORN TO ME THIS _____________ day of _______________20 _______.

____________________________
NOTARY PUBLIC
Until December 31, 20