Share

Change of Supervising Pharmacist

FDA RONPD form for change of supervising pharmacist

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
CHANGE OF SUPERVISING PHARMACIST

COMPANY NAME
COMPANY ADDRESS

:
:

NAME OF PREVIOUS
:
PHARMACIST
OWNER
:
SERVICE ENDED
:
NAME OF NEW
:
PHARMACIST
SERVICE BEGAN
:
LTO NUMBER
:
LTO 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 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 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. Credentials of Supervising Pharmacist
Is the new supervising pharmacist identified?
Identify the name under client’s remarks:
Is the PRC ID of the supervising pharmacist still valid?
If the PRC is not valid, is there a proof of renewal attached?
Is the resignation letter of new supervising pharmacist from
previous employer signed or received by the owner or
1

authorized representative of the establishment?
 Is the LTO number of the previous company indicated?


Is the name of pharmacist in the certificate of attendance to
FDA seminar on licensing of establishment the same with
application form for LTO?
 Is the seminar attended corresponds to the type of LTO
applied by the establishment?
 If not yet attended, is any proof of confirmation issued by the
FDA Academy of the scheduled licensing seminar included?
For pharmacists supervising more than one (1) RONPD:
 Is the list of other supervised pharmacies
indicated the addresses, LTO numbers and
supervising hours?
 Is the list conformed by each of the owners of
the RONPDs concerned?

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:

2
 
Page of
Share