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Department of Health
BUREAU OF FOOD AND DRUGS
Manila
IN THE MATTER OF PETITION OF
__________________________________
TO OPEN A FOOD ESTABLISHMENT
MORE PARTICULARLY AS A :
( ) Manufacturer/Processor
( ) Repacker
( ) Importer/Trader
( ) Exporter
--------------------------------------------------PETITIONER
COMES ON the undersigned petitioner unto the Bureau of Food and Drugs,
Department of Health, Manila, respectfully alleges:
FIRST
- That the petitioner is of legal age, married/single, Filipino citizen and
residing at,____________________________________________________________
SECOND - That he desires to open a food establishment, more particularly
as a ____________________________________________ of food and drug products
be located at _______________________________________ and shall be
known as ________________________________________________,
THIRD
That the said establishment with a capital / investment of
Pph_____________ is owned by ________________________ with postal address,
at_____________________________________________ and with Tel. No._______
FOURTH That the petitioner hereby agrees to change the business name or
corporate name of the establishment in the event that there is a similar or same name
registered with the Bureau of Food and Drugs or if it rules later that it is misleading;
WHEREFORE, the petitioner respectfully prays that he / she be granted License to
Operate said establishment after inspection thereof and after compliance with the Bureau of
Food and drugs requirements, rules and regulations, including but not limited to attached
BFAD - ILD Form No. 6, which is made as an integral part of this Petition.
Manila,Philippines,__________________________________________2009.
Respectfully submitted:
_____________________________
Printed Name of Petitioner
_____________________________
Signature
SUBSCRIBED AND SWORN to me this ___ day of ____________________
2006. Affiant exhibited to me his / her Residence Certificate No. ________________
issued at _______________________________ on _______________, 2009
_________________________________
Administering Officer
INFORMATION SHEET
(FOOD MANUFACTURING AND PROCESSING ESTABLISHMENT)
( ) New Establishment
( ) Presently Operating
I.
Name of Owner :
( ) Single Proprietorship
( ) Partnership
( ) Corporation
( ) Association
Respectfully submitted:
________________________________
Print Name and Sign above
__________________
Title
_________
Date
Name of Establishment:_________________________________________________________
Addres_________________________________________________Tel.#:__________________
Name of Owner/Manager:________________________________________________________
CAPITAL BREAKDOWN:
Equipment and supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
=____________________
Cost of the building/rental . . . . .. . . . . . . . . . . . . . . . . . . . . . . . = ____________________
Purchases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .= ___________________
Labels, cartoons, orders, etc. . . . . . . . . . . . . . . . . . . . . . . . . . . = ____________________
Salaries of the Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ____________________
Transport Utility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . = ___________________
Cash on hand/Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ____________________
Total Capitalization . . . = _____________________
__________________________________________
Owner/Manager Name & Signature
Subscribed
and
sworn
to
before
me
this
______
day
of
_____________________________
at
______________________________________________________________, Philippines. Affiant
exhibited to me his/her Residence Certificate No. _____________________________, issued on
______________________________________________.
_____________________________
NOTARY PUBLIC
PART-I
1. Name of Establishment: _______________________________________________________
Address: ________________________________________________ Tel.#: _____________
2. Name of Owner/President of Corporation: _________________________________________
3. License to Operate Number _____________________ Issued On: ______________________
Day Month
Year
Date of Last Renewal: _________________________
Day
Month
Year
4. Capital Invested: ______________________________
5. Number of Personnel:
Educational Attainment
a. Production ____________________________
_________________________________
b. Laboratory ____________________________ ________________________________
6. Production Manufactured:
Name of Products
Brand Name
Yes (
Yes (
Yes (
Yes (
Yes (
Yes (
Yes (
) No ( )
) No ( )
) No ( )
) No ( )
) No ( )
) No ( )
) No ( )
Yes ( )
No ( )
16. Areas:
1. Total Land Area: _________________________
2. Total Covered Area: ______________________
Interviewed by:
Received by:
___________________________________
__________________________________
FDRO Inspector
FDRO Inspector
E. Samples of the product and specifications of the finished product. (See attached list of
minimum product samples)
F. Labels & labelling materials to be used for the product.
G. Certificate of analysis. (Include analytical methods used)
H. Method of manufacturer, packing and quality control.
I. Stability data in support of declared Expiry date.
J. Certificate of agreement between the foreign manufacturer/distributor and the
importer/local distributor.
K. Government certificate of clearance and free sale of the product from the responsible
Government authority in the country of origin and duly authenticated by the Philippine
consulate abroad.
L. Evidence of registration for payment. (change slip/Official Receipt)
INITIAL REGISTRATION:
A. For Imported Products:
A. Exclusive distributor (source: direct from manufacturer)
Requirements: Nos. 1,2,4,5,6,7,8,9,10,11,12
B. Non-Exclusive (No currently marketed similar products)
Requirements: Nos. 1,2,4,5,6,10,11,12
Submit in a transparent sealable plastic bag together with the samples. (For inquiry ask Product
Services division, FOOD Section tel. # 842-45-38
Tel. #: ____________________________
____________________________________________
Printed Name of Pharmacist
___________________________________________
Signature
Res. Cert. #:______________________________
Issued on __________________________________
at ________________________________________
PTR #:____________________________________
Issued on__________________________________
at ______________________________________
Telephone #:________________________________
_________________________________
Administering Officer
Doc. No. _________________
Page No. _________________
Book No. ________________
Series of _________________
INSTRUCTIONS:
1. For single proprietorship, attached Certificate of Registration from the Bureau Of domestic Trade,
for corporation, partnership or other jurisdicial person, attached Certificate of Registration with
the Securities & Exchange commission, together with a copy of Article of incorporation and Bylaws. If the applicant is an alien, the petition must be accompanied by an authenticated copy of the
Certificate of alien Registration.
2. All drugs and cosmetic products, prior to their introduction into the domestic commerce, must first
be
registered with BFAD.
3.
AFFIDAVIT OF UNDERTAKING
I, ______________________________________________________________________________
(Family Name, First Name, Maiden Middle) Owner/Pharmacist with
PRC Registration Number: __________________________ Issued on _______________________
PTR No.: _________________________ Issued on _______________________
Of legal age, single/married and a resident of ___________________________________________
________________________________________________________________________________
(Permanent Home Address)
and owner/pharmacist of ____________________________________________________________
(Name of Company)
located at ________________________________________________________________________
(Address of Company)
after having been sworn in accordance with law, hereby declare:
1. that I am fully aware of the provision of Pharmacy Law, the Foods, Drugs, Devices and
Cosmetic Act, the Generics Act of 1988 and that I am aware of the specific requirements that the
operation of ____________________________________ shall be under my IMMEDIATE
AND PERSONAL SUPERVISION with business hours being from ________________ AM
to _______________ PM;
2. that I agree to change the business name if there is already a validly registered name similar to
business name;
3. that I shall display the approved License to Operate in a conspicuous place of my establishment;
4. that I shall notify BFAD 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 pharmacist-incharge and change in drug products;
5. and that I, the pharmacist-in-charge, am not and will not be in any way be connected with any
drug or similar establishment/outlet;
WITHNESS WHEREOF, I hereunto affix my signature this ___ day of ________, 2009
_______________________________________
(Signature of Affiant)
Residence Cert. No. ______________________
Issued on:_______________________________
At _____________________________________
SUBSCRIBED AND SWORN TO ME THIS _______ day of __________________, 2009
at ____________________________________________________.
____________________________________
NOTARY PUBLIC
Until December 31, 200______
Doc. no. ________
Book No. _______
Page No. ________
Series of ________
____________________________________PHARMACIST - IN - CHARGE
with PRC Registration No.______________________
issued on____________________________________
PTR No.____________________________________
of legal age, single / married, and a resident of _________________________________________
and _____________________________________________________owner of
___________________________________________________________________________
(drug establishment)
located at ____________________________________________________________________
of legal age and a resident of _____________________________________________________
after having been sworn in accordance with laws, hereby declare;
1) That we are fully aware of the provisions of the Pharmacy Law, the Foods, Drugs and
Devices And Cosmetics Act, the Generics Act of 1980 and 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 _______A..M. to ______ P.M.;
2) That we agree to change the business name if there is already validly registered name similar
to our business name;
3) That we shall display our approved License to Operate in a conspicuous place of our
establishment;
3) And that we shall notify BFAD in case of any change(s) in the circumstances of our
application for a License to Operate, were specifically including but not limited to change(s)
of location, change of pharmacist-in-charge; an change in drug products.
We execute this Joint Affidavit of Undertaking of confirm the truth of our declaration and our
awareness of the foregoing duties and responsibilities among others.
WITNESS HEREOF, we hereunto affix our signatures this ______ day of _______________,
2004.
___________________________________
Owners Name & Signature
Res. Cert. No.________________________
Issued on. ___________________________
at __________________________________
_______________________________________
Pharmacist Name & Signature
Res. Cert. No.__________________________
Issued on _____________________________
at ___________________________________
a duly registered pharmacist with Registration Certificate No. ___________issued on ____________, 200__
with Privilege Tax Receipt No. ________________(PTR) dated _______________, 200__ is the pharmacist
in- charge of ______________________________________located at _______________________________
________________________________________________ with office hours from _____ A.M. ______P.M.
(Attached photocopy of Certificate of registration and 2x2 latest picture)
This certification is further authenticated by the above mentioned pharmacist with signature appears below.
____________________________________
Date
________________________________________
Printed Name of Pharmacist
____________________________________
Printed Name of Owner
_________________________________________
Signature
_____________________________________
Signature
_________________________________________
Address
_______________________________
Address
Owner : ____________________________________
Address : ___________________________________
Res. Cert. No. ___________________
Issued at _______________________
on _______________________
Tel. No. ________________________
SUBSCRIBED AND SWORN TO BEFORE ME THIS_____ day of ___________, 200__ Exhibited this/their
Residence Certificate, the date of which are indicated below his/her respective name on page one hereof.
Doc. No. _________________________
Page No. ________________________
Book No. _______________________
Series No. _______________________
___________________________________
NOTARY PUBLIC
____________________________________PHARMACIST - IN - CHARGE
with PRC Registration No.______________________
issued on____________________________________
PTR No.____________________________________
of legal age, single / married, and a resident of _________________________________________
and _____________________________________________________owner of
___________________________________________________________________________
(drug establishment)
located at ____________________________________________________________________
of legal age and a resident of _____________________________________________________
after having been sworn in accordance with laws, hereby declare;
1) That we are fully aware of the provisions of the Pharmacy Law, the Foods, Drugs and
Devices And Cosmetics Act, the Generics Act of 1980 and 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 _______A..M. to ______ P.M.;
2) That we agree to change the business name if there is already validly registered name similar
to our business name;
3) That we shall display our approved License to Operate in a conspicuous place of our
establishment;
3) And that we shall notify BFAD in case of any change(s) in the circumstances of our
application for a License to Operate, were specifically including but not limited to change(s)
of location, change of pharmacist-in-charge; an change in drug products.
We execute this Joint Affidavit of Undertaking of confirm the truth of our declaration and our
awareness of the foregoing duties and responsibilities among others.
WITNESS HEREOF, we hereunto affix our signatures this _______ day of _______________,
2006.
___________________________________
Owners Name & Signature
Res. Cert. No.________________________
Issued on. ___________________________
at __________________________________
_______________________________________
Pharmacist Name & Signature
Res. Cert. No.__________________________
Issued on _____________________________
at ___________________________________
______________________________________
Notary Public
P H A R M A C I S TS
AFFIDAVIT
a duly registered pharmacist with Registration Certificate No. ___________issued on ____________, 2006_
with Privilege Tax Receipt No. ________________(PTR) dated _______________, 2006 is the pharmacist
in- charge of ______________________________________located at _______________________________
________________________________________________ with office hours from _____ A.M. ______P.M.
(Attached photocopy of Certificate of registration and 2x2 latest picture)
This certification is further authenticated by the above mentioned pharmacist with signature appears below.
____________________________________
Date
________________________________________
Printed Name of Pharmacist
____________________________________
Printed Name of Owner
_________________________________________
Signature
_____________________________________
Signature
_________________________________________
Address
_____________________________________
Address
SUBSCRIBED AND SWORN TO BEFORE ME THIS_____ day of ___________, 2006 Exhibited this/their
Residence Certificate, the date of which are indicated below his/her respective name on page one hereof.
___________________________________
NOTARY PUBLIC
_______________________________________
OWNER