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Zonal Change in Address

FDA drugstore form for zonal change in address

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
ZONAL CHANGE IN ADDRESS

COMPANY NAME
COMPANY ADDRESS

:
:

NEW 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

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?
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. Document Issued by Local Municipality as Proof of Zonal Change
 Is the document issued by the local municipality reflects the
zonal change?
 Is the document duly signed by the incumbent local official or
its authorized signatory?

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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?
--- 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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