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Deletion of Activity

FDA drug manufacturer form for deletion of activity

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Department of Health
FOOD AND DRUG ADMINISTRATION

CENTER FOR DRUG REGULATION AND RESEARCH
DRUG MANUFACTURER (

) / PACKER (

) / REPACKER (

) TRADER (

)

SELF-ASSESSMENT TOOLKIT FORM
DELETION OF ACTIVITY

COMPANY NAME
COMPANY ADDRESS

:
:

ACTIVITY TO BE
:
DELETED
OWNER
:
LTO NUMBER
:
VALIDITY
:
Directions:
Fill out the form by ticking the applicable box. Provide remarks on the client’s column when necessary.
Submit in Portable Document Format (pdf) and word format duly signed by the pharmacist/owner.

DOCUMENTARY REQUIREMENTS:

Yes

No

REMARKS
CLIENT

FDA

1. Application Form
 Is the integrated application form properly filled out?
 Is it duly notarized?
 Are the signatories in the application form the authorized
persons as required under the following circumstances?
(a) If single proprietorship – the owner as registered in DTI
(unless there is a different authorized person)
(b) If partnership/corporation – one of the incorporators or
authorized person as indicated in the board resolution or
Secretary’s Certificate
(c) If cooperative – authorized person indicated in the
board resolution or Secretary’s Certificate of the
cooperative
If the signatory is not the owner or one of the incorporators, as
the case may be:

Is there a board resolution or notarized Secretary’s
Certificate clearly identifying the person authorized to sign
for and in behalf of the owner or corporation submitted?
2. Termination of Contract/Agreement or Conformance Letter
 Is the termination contract or conformance letter valid/duly
signed by both parties?
3. Proof of Payment
 Is the payment made according to the required fee?
 Is there a scanned copy of proof of payment (e.g FDA official
receipt, Landbank On-coll validated slip) submitted?
Note: If the following is/are not submitted in the initial application, the said document/s shall be attached:
 Risk Management Plan (RMP) or commitment letter while the official RMP framework from FDA is not yet issued
 GPS Coordinates
NOTE: ADDITIONAL DOCUMENTS MAY BE REQUIRED TO BE SUBMITTED AS DEEMED NECESSARY.
--- To be filled out by client: --Prepared by:
Signature:
Position (Pharmacist / Owner):
Date:

--- To be filled out by RFO: --Decision:
Approval
Denial

Remarks:

Clarification

Inspection

Evaluated by:

Decision:
Approval
Clarification
Evaluated by:

Date:

Remarks:

--- To be filled out by CDRR: ---

Date:
 
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