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Expansion of Establishment
FDA drugstore form for expansion of establishment
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
EXPANSION OF ESTABLISHMENT
COMPANY NAME
COMPANY ADDRESS
:
:
ADDITIONAL SITE
ADDRESS
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
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?
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 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: ---
REMARKS
CLIENT
FDA
)
Prepared by:
Position (Pharmacist / Owner):
Decision:
Approval
Denial
Signature:
Date:
--- To be filled out by RFO: ---
Remarks:
Clarification
Inspection
Evaluated by:
Date:
--- To be filled out by CDRR: --Decision:
Approval
Clarification
Evaluated by:
Remarks:
Date:
