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Petition Form

FDA form for petition (except NCR and Region 4A)

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
Filinvest Corporate City
Alabang, City of Muntinlupa

CENTER FOR COSMETICS REGULATION AND RESEARCH
ANNEX C
IN THE MATTER OF PETITION OF:
_____________________________________________________________
(Name of Owner/Incorporator/Authorized Representative of Establishment)
TO OPEN A COSMETIC ESTABLISHMENT PARTICULARLY AS:

2x2
Picture
(Owner)

( ) Manufacturer
( ) Trader
( ) Distributor
_________________________________________________________________________________________________

PETITION
COMES now the undersigned petitioner unto the Food and Drug Administration, Department of Health, Manila respectfully
alleges;
FIRST – That the petitioner is of legal age, married/single, Filipino citizen and residing
__________________________________________________________________________(Complete Home Address);

at

SECOND – That the petitioner desires to open a cosmetic establishment particularly as _____________________ to be
located at ___________________________________________________________________________________________
(Flr.)
(Bldg.)
(No.)
(Street)
(Subdivision)
(Brgy.)
(City) (Province)
and shall be known as _____________________________________________________________(Exact Business Name);
THIRD – That the petitioner has the authority to file this application as the:
( ) Sole Proprietor/Owner
( ) Incorporator
( ) Authorized Representative of Establishment;
FOURTH - That said establishment shall be open for business from _______ A.M. to ______P.M. and shall be under the
personal and immediate supervision of _________________________________________, an authorized person with
(Name of Authorized Person [Pharmacist or any Allied Health Science Profession])
PRC Certificate of Registration No.: ___________________ issued on _______________valid until _____________;
(DD/MM/YY)
(DD/MM/YY)
FIFTH – That the petitioner hereby agrees to change the business name of the establishment in the event that there is a
similar or same name registered with the Food and Drug Administration if it rules later that it is misleading;
SIXTH – That the petitioner will be held liable for not informing FDA of any changes in circumstances or amendments;
SEVENTH – That the amount of Capital invested for said establishment is Php ________________________; and
EIGHTH – That the petitioner and the establishment’s registered Authorized Person shall sign a joint affidavit of
undertaking.
WHEREFORE, the petitioner respectfully prays that he/she be granted a License to Operate as a cosmetic establishment
after inspection thereof and after compliance with the requirements, rules and regulations of the Food and Drug
Administration.
_____________Philippines _________________, 20 _____.
(City,Province)
(DD/MM)
Respectfully submitted by:
___________________________________________________
SIGNATURE OVER PRINTED NAME OF PETITIONER
Contact Number/s.:___________________________________
E-mail Address: _____________________________________
VERIFICATION
Petitioner after having sworn in accordance wit law, hereby states that:
(1) He / She is the petitioner in the above entitled petition;
(2) The Petitioner has caused the preparation of the said petition and
has read and understood the contents thereof; and
(3) The allegations are true and correct to his/her knowledge.
 
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