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Local Order Permit Application

FDA application form for local order permit for dangerous drugs

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LOCAL ORDER PERMIT APPLICATION for Dangerous Drugs, its Preparation and Table 1 Controlled Chemical/s used in
the manufacture of Dangerous Drugs Preparation/s or its Pharmaceutical Preparation/s
Date: ______________________
Request for approval to purchase/transfer the following Dangerous Drugs (DD) and/or their preparation/s (DDP) from
Name of Supplier / Source: __________________________________________________________________________________
with business address at ____________________________________________________________________________________
Current S-License Number_______________________________________________ Valid until____________________________
GENERIC NAME/
RAW MATERIAL/S

BRAND NAME

Dosage Dosage
Strength Form

QUANTITY ORDERED/
TO BE USED

Packaging Balance on Hand
Previous
Presentation as of request
Approved LOP #
(e.g. pcs/bxs/kgs)
date

1.
2
3.
4.
5.
ENCIRCLE INTENDED PURPOSE OF SUBJECT DD / DDP: Transfer to S3 / Transfer to S2 / Transfer to S6 / Manufacture / Destruction /
Returned Stocks / Evaluation / Medical Mission / Donation / Surrender to PDEA Laboratory Service/ Transfer to Court /
FDA Registration sample / Reference Standard / Others Transfer (e.g. Transfer to - S4/S5I/S5C/S5D): ______________________.
Name and Signature of Authorized Pharmacist:________________________ PRC No._______ Exp._______/PTR _______Dated____
Name of Entity: _________________________________________________ Address: ______________________________________
Current S- License Number: _______________________________________ Valid Until ___________________________________

REMINDERS:
1. ONLY LEGIBLE AND COMPLETELY FILLED-OUT FORM WITH CORRECT DATA WILL BE PROCESSED.
2. ANY CHANGES/CORRECTION IN DATA PRIOR APPROVAL SHALL BE MADE & SIGNED BY THE AUTHORIZED PHARMACIST. (USE ONLY ONE SIGNATURE)
3. COORDINATION TO BE MADE WITH SUPPLIER ON STOCK AVALABILITY PRIOR TO LOP APPROVAL. SUPPLIER NOT TO DELIVER INSUFFICIENT QUANTITY ORDERED.
NO ALTERATION ALLOWED ONCE APPROVED.
4. A REPRESENTATIVE IS ALLOWED TO TRANSACT UPON SUBMISSION OF AN AUTHORIZATION LETTER AND PHOTOCOPY OF VALID ID OF REPRESENTATTIVE.
5. TO SECURE AN APPROVED LOP PRIOR TRANSFER/ SURRENDER OF DANGEROUS DRUG TO PDEA LABORATORY SERVICE.

(APPLICANT’S COPY)
--------------------Please cut here ----------------------------------- Please cut here --------------------------- Please cut here----------------------------FM-CSVlrd-09
LOCAL ORDER PERMIT APPLICATION for Dangerous Drugs, its Preparation and Table 1 Controlled Chemical/s used in
the manufacture of Dangerous Drugs Preparation/s or its Pharmaceutical Preparation/s
Date: ______________________
Request for approval to purchase/transfer the following Dangerous Drugs (DD) and/or their preparation/s (DDP) from
Name of Supplier / Source: __________________________________________________________________________________
with business address at ____________________________________________________________________________________
Current S-License Number_______________________________________________ Valid until_____________________________
GENERIC NAME/
RAW MATERIAL/S

BRAND NAME

Dosage Dosage
Strength Form

QUANTITY ORDERED/
TO BE USED

Packaging Balance on Hand
Previous
Presentation as of request
Approved LOP #
(e.g. pcs/bxs/kgs)
date

1.
2
3.
4.
5.
ENCIRCLE INTENDED PURPOSE OF SUBJECT DD / DDP: Transfer to S3 / Transfer to S2 / Transfer to S6 / Manufacture / Destruction /
Returned Stocks / Evaluation / Medical Mission / Donation / Surrender to PDEA Laboratory Service / Transfer to Court /
FDA Registration sample / Reference Standard / Other Transfer (e.g. Transfer to - S4/S5I/S5C/S5D): ______________________.
Name and Signature of Authorized Pharmacist:________________________ PRC No._______ Exp._______/PTR _______Dated____
Name of Entity: _________________________________________________ Address: ______________________________________
Current S- License Number: _______________________________________ Valid Until ___________________________________
(PDEA COPY)
_______________________________________
PRINTED NAME AND SIGNATURE OF RECEIVER
(AUTHORIZED PHARMACIST OR REPRESENTATIVE)

TIME
RECEIVED
PROCESSED
APPROVED/PRINT
TOTAL TIME

:_______
:_______
:_______
:_______ mins.

AUTHORIZATION
DATE: __________________

Director General
PHILIPPINE DRUG ENFORCEMENT AGENCY
NIA Northside Road, National Government Center
Brgy. Pinyahan, Quezon City
ATTENTION: DIR III HELEN MAITA E. REYES, RPH, MBA, MGM
Director, Compliance Service
Dear Ma’am
I hereby authorize the bearer_________________________________ whose signature appears below to submit the application for
the Local Order Permit subject for approval in my behalf.
I shall be accountable for any violation/s that might be committed for the said transaction.

___________________________________________
Printed Name and Signature of Authorized Pharmacist

______________________________________________
Printed Name and Signature of Authorized Representative

REMINDER: PLEASE ATTACH PHOTOCOPY OF VALID ID OF AUTHORIZED REPRESENTATIVE. FOR STRICT COMPLIANCE

AUTHORIZATION
DATE: __________________

Director General
PHILIPPINE DRUG ENFORCEMENT AGENCY
NIA Northside Road, National Government Center
Brgy. Pinyahan, Quezon City
ATTENTION: DIR III HELEN MAITA E. REYES, RPH, MBA, MGM
Director, Compliance Service
Dear Ma’am
I hereby authorize the bearer_________________________________ whose signature appears below to submit the application for
the Local Order Permit subject for approval in my behalf.
I shall be accountable for any violation/s that might be committed for the said transaction.

___________________________________________
Printed Name and Signature of Authorized Pharmacist

______________________________________________
Printed Name and Signature of Authorized Representative

REMINDER: PLEASE ATTACH PHOTOCOPY OF VALID ID OF AUTHORIZED REPRESENTATIVE. FOR STRICT COMPLIANCE
 
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