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Petition Form

The document is a petition to open a drug establishment in the Philippines. It provides details about the petitioner such as their address and role. It also provides details about the proposed establishment such as its address, hours of operation, and appointed pharmacist. The petitioner agrees to comply with rules and requests a license after inspection.

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Amaeten
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2K views

Petition Form

The document is a petition to open a drug establishment in the Philippines. It provides details about the petitioner such as their address and role. It also provides details about the proposed establishment such as its address, hours of operation, and appointed pharmacist. The petitioner agrees to comply with rules and requests a license after inspection.

Uploaded by

Amaeten
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

Department of Health
FOOD AND DRUG ADMINISTRATION
Filinvest Corporate City
Alabang, City of Muntinlupa
QWP-007-030-01-ANNEX-01-1

IN THE MATTER OF PETITION OF:


___________________________________________ 2x2
(Name of Owner) Picture
TO OPEN A DRUG ESTABLISHMENT PARTICULARLY AS A: (Owner)
( ) Retail Drugstore
( ) Hospital Pharmacy
( ) Retail Outlet for Non-Prescription Drugs
( ) Drug Distributor ( ) Importer ( ) Exporter ( ) Wholesaler

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 at
__________________________________________________________________________;
(Complete Address)
SECOND That the petitioner desires to open a drug 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 ( ) Attorney-in-fact ( ) Authorized Representative;
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 _________________________________________, a duly registered pharmacist with Certificate of

Registration No. ___________________issued on ____________________;

FIFTH That ___________________________ is the owner of said establishment with postal address at
___________________________________________________________________________;

SIXTH 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;

SEVENTH That the amount of Capital invested for said establishment is Php ________________________; and

EIGHTH That the petitioner and the establishments registered pharmacist shall sign a joint affidavit of undertaking.

WHEREFORE, the petitioner respectfully prays that he/she be granted a license to operate a drug establishment after inspection
thereof and after compliance with the requirements, rules and regulations of the Food and Drug Administration.

Manila, Philippines __________________, 20 _____


Respectfully submitted by:

_________________________________________________
SIGNATURE OVER PRINTED NAME OF OWNER

Res. Cert. No.: _____________________________


Issued on: _________________________________
Issued at: __________________________________
Tel. No. :__________________________________
VERIFICATION

Petitioner after having sworn in accordance with 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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