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Change of Ownership

FDA drugstore form for change of ownership

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
DRUGSTORE (

) / HOSPITAL PHARMACY (

) / INSTITUTIONAL PHARMACY (

)

SELF-ASSESSMENT TOOLKIT FORM
CHANGE OF OWNERSHIP

COMPANY NAME
COMPANY ADDRESS

:
:

PREVIOUS OWNER
NEW OWNER
LTO NUMBER
VALIDITY
ACTIVITY

:
:
:
:
:

RETAILING
STERILE COMPOUNDING
MOBILE PHARMACY

NON-STERILE OMPOUNDING
ONLINE ORDERING AND DELIVERY

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 for LTO
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?
For government-owned or controlled corporation:






Is there an Order (or equivalent document) identifying
the person authorized to sign for and in behalf of the
establishment submitted?

2. Proof of Business Name Registration
(a) For single proprietorship, Certificate of Business
Registration issued by the Department of Trade and
Industry (DTI)
 Is the business name applied for LTO the same with that
of DTI registration certificate?

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 Is the DTI certificate still valid?
 Is the owner appearing in the application form the same
with that of the DTI certificate?
 Is the address of the establishment applying for LTO
within the territorial coverage? If the business address
indicated in DTI is different from the exact address as
declared in the application form, is there a clear copy of
Business/Mayor’s Permit or Barangay clearance
indicating the complete address of drug establishment?
(b) For corporation, partnership and other juridical
person, Certificate of Registration issued by the
Securities and Exchange Commission (SEC) and
Articles of Incorporation
 Is the business name applied for LTO the same with that
of the SEC registration certificate? If the company uses
another business name style different from its corporate
name, is an amended SEC registration reflecting the same
submitted?
 Is the address indicated in the SEC the same with the
address of the establishment applied for LTO?
o If the address in SEC is still occupied but
the business operation applied for LTO is
located in a separate area, is a clear
scanned copy of Business /Mayor’s Permit
or Barangay clearance indicating the
complete address of drug establishment
submitted?
o If the address in SEC is no longer
occupied, is an amended SEC registration
reflecting the current business address
submitted?
 Is the type of activity and product applied for LTO
indicated in the Articles of Incorporation (Article II)?
(c) For cooperative, Certificate of Registration issued by
the Cooperative Development Authority and the
approved by-laws
 Is the business name applied for LTO the same with that
of the CDA registration certificate?
 Is the address indicated in the CDA the same with the
address of the establishment applied for LTO?
 Is the type of activity and product applied for LTO
indicated in the approved articles and by-laws of the
cooperative?
(d) For government-owned or controlled corporation
 Is there a copy of the law creating the same? (if with
original charter)
Note: If the drugstore is not owned by the government,
certificate of business name registration shall follow the
requirements under 2.a,b,c (where applicable).
3. Deed of sale or transfer of rights
 Is it duly notarized?
 Are the previous and new owners correctly identified?
 For franchise establishments, is there a deed of sale or
transfer of rights of franchise agreement submitted?
 Is it duly notarized?
 Is it conformed by the franchisor?

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4. 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?
--- To be filled out by client: --Prepared by:
Signature:
Position (Pharmacist / Owner):
Date:
--- To be filled out by RFO: --Decision:
Remarks:
Approval
Denial
Clarification
Inspection
Evaluated by:
Date:

--- To be filled out by CDRR: --Decision:
Approval
Clarification
Evaluated by:

Remarks:

Date:

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