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Zonal Change
FDA RONPD form for zonal change
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
RETAIL OUTLET FOR NON-PRESCRIPTION DRUGS
SELF-ASSESSMENT TOOLKIT FORM
ZONAL CHANGE - TRANSFER OF LOCATION
COMPANY NAME
COMPANY ADDRESS
:
:
PREVIOUS ADDRESS
:
NEW ADDRESS
:
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
1. Application Form
Is the integrated application form properly filled out?
Is it duly notarized?
Are the signatories of 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
and/or Secretary’s Certificate
(c) If cooperative – authorized person indicated in the
board resolution and/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 establishments:
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 reflecting the
zonal change?
Is the document duly signed by the incumbent local official or
its authorized signatory?
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: ---
REMARKS
CLIENT
FDA
Prepared by:
Position (Pharmacist / Owner):
Signature:
Date:
--- To be filled out by RFO: ---
Decision:
Approval
Denial
Clarification
Inspection
Remarks:
Evaluated by:
Date:
--- To be filled out by CDRR: ---
Decision:
Approval
Clarification
Evaluated by:
Remarks:
Date:
