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Email Worksheet

The application form has six parts: 1) General


SUBJECT:
Information, 2) Establishment Information, 3) Product
Information, 4) Supporting Information, 5) Sources and
Clients, and 6) Applicant Information. In the worksheet
'Form' (with the red tab) you will see a dashboard where
the different parts are identified. If the part is
appropriately filled up, a green 'PROCEED' will be
BODY:
indicated.Required fields will appear sequentially.To
minimize errors and confusion, it is recommended that a
blank form be used for every application. If the form is
appropriately filled up, the composed body text (in the
green box) will appear.
Be careful to paste the body text completely as text
Printing Instructions
(not as an image or as an attachment). DON'T attach any
(Please print the following p
file to the email request.
For Drug Registra
For Non-Drug Registra
For Licen

Application Process Overview

DUC-Z PHARMACEUTICALS#IX

BEGIN:LTO;CDRR;DUC-Z
PHARMACEUTICALS#IX#Wholesaler#0;RNW
#0#0#1#0#0####0;10000;100;36000;461
00:END

IMPORTANT
READ THIS PAGE
CAREFULLY.
Provide information only
when asked for.

rinting Instructions

Please print the following parts of the worksheet 'Form' if applicable)


For Drug Registration (excluding amendments and compliances): pages 1 and 4.
For Non-Drug Registration (excluding amendments and compliances): pages 1 and 3.
For Licensing (exclusing amendments and compliances): pages 1 and 2.
For All Other Applications: page 1 only.

PAGE
.
ormation only
d for.

ages 1 and 4.
ages 1 and 3.
ages 1 and 2.
age 1 only.

APPLICATION F

This is the application form. Witho


appropriate petition or declaration
application may be rejected.

APPLICATION FORM STATU

Document Tracking Number


Description (Optional):

1 GENERAL INFORMATION

PROCEED

1.1 Product Center: Drug


1.2 Authorization: License to Operate
1.3 Type: Renewal
1.4 Primary Activity: Wholesaler

GENERAL INFORMATION:
ESTABLISHMENT INFORMATION:
PRODUCT INFORMATION:
SUPPORTING INFORMATION:
SOURCES & CLIENTS:
APPLICANT INFORMATION:

ORDER OF PAYMENT
Amount Due: Php
Fee : Php
Legal Research Fee : Php
Surcharge : Php
OR Number :
Date Paid:

Computation Valid Until:

TURNED INITIAL

03 Oc

This form was last edited on 08 April 2015, 5:3

CDRR-RIX-DW-148

03-Jul-15

NO

4 SUPPORTING INFORMATION
PROCEED

2 ESTABLISHMENT INFORMATION PROCEED


2.1 Name of Establishment
DUC-Z PHARMACEUTICALS

2.3 Tax Identification Number: 403-376-459-000


2.4 Office Address
2.5.1 Region: IX
GONZALES ST., BIASONG, DIPOLOG CITY
2.5 Warehouse Address

2.6.1 Region: IX

GONZALES ST., BIASONG, DIPOLOG CITY

2.7.0
2.7.1
2.7.2
2.7.3

E-mail Address:
Contact Detail 1
Contact Detail 2
Contact Detail 3

robert.dampor@yahoo.com

Landline:
Mobile:
Fax:

NA
9177262049
NA

PROCEED

License to Operate

This is the petition form for establishmen

We categorically declare that all data and information submitted in


amendments, are true, correct, and reflect the total information availab

I/we am/are duly authorized to affirm the following declaration on b

I. The said establishment shall be open for business hours under the su

II. The pharmacist and other allied health professionals, upon and durin
other FDA-regulated establishment (if applicable);

III. The approved and valid License to Operate shall be displayed in a co

IV. To change the business name of the establishment and/or brand nam
Drug Administration, or if the FDA rules later that it is misleading;

V. The attached electronic copy of files/documents/information of the LT


or willful misrepresentation on any of the data therein shall be a ground
company;
VI. If applying for automatic renewal:

a. Have filed the application, and have paid the complete & appropria

B. That there are no changes or variations in the establishment since


change of business name, change of registered pharmacist, change in
personnel;

VII. The products we manufacture, distribute and/or sell are registered o


responsibility and/or stewardship over the product in case of liability, ad

VIII. The establishment whether for initial, renewal or automatic renewa


undertake to respond and cooperate fully with the FDA with regard to an

IX. Non-compliance with the requirements and/or failure to give notice t


circumstances in relation to the approval of this application is a ground f

IX. Non-compliance with the requirements and/or failure to give notice t


circumstances in relation to the approval of this application is a ground f

X. Any violation of the above provisions and rules and regulations will a
Operate.

XI. I/We make this declaration in full knowledge and awareness of Repu
Administration Act of 2009, other allied laws and their implementing rul

WHEREFORE, the undersigned confirm the truth of our declaration and a


application for License to Operate be granted after compliance with the

I HEREBY GRANT AUTHORITY TO THE FOOD AND D


RESOURCES THE AUTHENTICITY

SUBSCRIBED AND SWORN TO BEFORE ME this _______ day

_______________________________________________________, Philippines, pers


Name and Signature

Socia

1) ROBERT TITO IBAEZ DAMPOR


2) LILIA TACLOB AGOT

Known to me and to me known to be the same persons who execute th


free and voluntary act and deed. WITNESS MY HAND AND SEAL on the d
Doc. No. : _____________________________
Page No. : ____________________________
Book No. : ____________________________

Book No. : ____________________________


Series of : _____________________________

1) Raw Material, Additive or Ingredient;


2) Raw Material, Additive or Ingredient;
3) Raw Material, Additive or Ingredient;
4) Raw Material, Additive or Ingredient;
5) Raw Material, Additive or Ingredient;
6) Raw Material, Additive or Ingredient;
7) Raw Material, Additive or Ingredient;
8) Raw Material, Additive or Ingredient;
9) Raw Material, Additive or Ingredient;
10) Raw Material, Additive or Ingredient;

1) Raw Material, Additive or Ingredient;


2) Raw Material, Additive or Ingredient;
3) Raw Material, Additive or Ingredient;
4) Raw Material, Additive or Ingredient;
5) Raw Material, Additive or Ingredient;
6) Raw Material, Additive or Ingredient;
7) Raw Material, Additive or Ingredient;
8) Raw Material, Additive or Ingredient;
9) Raw Material, Additive or Ingredient;
10) Raw Material, Additive or Ingredient;
11) Raw Material, Additive or Ingredient;
12) Raw Material, Additive or Ingredient;
13) Raw Material, Additive or Ingredient;
14) Raw Material, Additive or Ingredient;
15) Raw Material, Additive or Ingredient;

1) Active Pharmaceutical Ingredient;


2) Active Pharmaceutical Ingredient;
3) Active Pharmaceutical Ingredient;
4) Active Pharmaceutical Ingredient;
5) Active Pharmaceutical Ingredient;
6) Active Pharmaceutical Ingredient;
7) Active Pharmaceutical Ingredient;
2)
8) Active
Active Pharmaceutical
Pharmaceutical Ingredient;
Ingredient;
3) Active
Active Pharmaceutical
Pharmaceutical Ingredient;
Ingredient;
9)
4) Active
10)
ActivePharmaceutical
PharmaceuticalIngredient;
Ingredient;
11)
ActivePharmaceutical
PharmaceuticalIngredient;
Ingredient;
5) Active
12)
Active
Pharmaceutical
Ingredient;
6) Active Pharmaceutical Ingredient;
7) Active Pharmaceutical Ingredient;
8) Active Pharmaceutical Ingredient;
9) Active Pharmaceutical Ingredient;

10) Active Pharmaceutical Ingredient;


11) Active Pharmaceutical Ingredient;
12) Active Pharmaceutical Ingredient;

CLIENTS
ON FORM 51SOURCES &None
m. Without the

laration form, this


d.

STATUS
ATION: PROCEED
ATION: PROCEED
ATION: PROCEED
ATION: PROCEED
IENTS: PROCEED
ATION: PROCEED

Php

hp
hp
hp

46,100.00

10,000.00
100.00
36,000.00

03 October, 2015

2015, 5:35 PM.

ATION

Add or
Delete?

PROCEED

PROCEED

PROCEED

6 APPLICANT INFORMATION

The undersigned attest to have provided true and complete information in this fo
requirements at the time of submission. The undersigned agree to strict complia
Food and Drug Administration (FDA), including Good Manufacturing Practice (GM
(GDSP), Good Pharmacy Practice (GPP), and/or Good Laboratory Practice (GLP). F
authority to the FDA to verify the truthfulness of the information provided with th

6.1 APPROVING AUTHORITY


Signature

Latest photo of applicant

6.1.2 Designation:
6.1.3 Tax ID Number:
6.1.4.0 Type of Gov't ID:
6.1.4.1 ID Number:
6.1.4.2 Date Expiry:

6.2 APPLICANT

6.1.1.0 Family
Name:
6.1.1.1 First
Name(s):
6.1.1.2 Middle
Name:

DAMPOR
ROBERT TITO
IBAEZ

Owner/ General Manager/ President


403-376-459
Social Security System
100-909-2063
NA
Signature

PROCEED

Latest photo of applicant

6.2.2 Designation:

6.2.2.0 Family
Name:
6.2.2.1 First
Name(s):
6.2.2.2 Middle
Name:

AGOT
LILIA
TACLOB

Company Pharmacist

6.2.3 Tax ID Number:


6.2.4.0 Type of Gov't ID:
6.2.4.1 ID Number:
6.2.4.2 Date Expiry:

204-557-030-000
Professional Regulatory Commission
20092
28-Jul-15

shment licensing by the Food and Drug Administration of the Philippines.

PETITION

ted in connection with this application as well as other submissions in th


vailable.

n on behalf of the Company:

DUC-Z PHARMACEUTICALS

the supervision of a PRC registered professional (if applicable) or authorized

during employment in this establishment, is/are not and will not in any wa

in a conspicuous place of the establishment;

nd name of products in the event that there is a similar or same name regis

the LTO application are the exact duplicate of the hard copy and, any discr
round for disapproval of application and/or the filing of legal action against

propriate renewal fee before expiry date;

since the last renewal of LTO specifically but not limited to change of locat
ange in warehouse site, additional supplier and product lines, change in act

tered or to be registered with FDA prior to distribution or sale, and that we


ity, adverse events, and/or other public health & safety issues;

enewal, is still subject to inspection by FDAs authorized representatives at


d to any subsequent post-marketing activity;

otice to the FDA of the change in business address, business name, owners
ound for revocation of the License to Operate;

will automatically be subject to the SUSPENSION/ CANCELLATION/ REVOCA

Republic Act No. 3720, as amended by Republic Act no. 9711, otherwise k
ing rules and regulations.

and awareness of the foregoing duties and responsibilities among others,


th the Food and Drug Administrations requirements.

WAIVER

AND DRUG ADMINISTRATION TO VERIFY THROUGH BOTH GOVERNMENT AN


NTICITY OF ALL THE INFORMATION AND DOCUMENTS SUBMITTED .

ACKNOWLEDGEMENT

__ day of _________________ 20________ at ______________________________

s, personally appeared the following :


Identification Number

Expiry Date of ID

Social Security System:100-9092063

NA

Professional Regulatory
Commission:20092

28-Jul-15

___________

___________

ute the application form and this petition form, and they acknowledged to
n the date and place first above written.

Provide in this space a description of the


Provide in this space a description of the
product in terms of rheology, thermal, and
product in terms of color, texture, functional geometry properties among others, as
properties, flavor, among others, as
applicable; Indicate if appropriate
applicable.
microbiological cultures present in the

Provide in this space a description of the


Provide in this space a description of the
product in terms of rheology, thermal, and
product in terms of color, texture, functional geometry properties among others, as
properties, flavor, among others, as
applicable; Indicate if appropriate
applicable.
microbiological cultures present in the
product

1)
2)
3)
4)
5)
6)
7)
8)
9)

API
API
API
API
API
API
API
API
API

Manufacturer,
Manufacturer,
Manufacturer,
Manufacturer,
Manufacturer,
Manufacturer,
Manufacturer,
Manufacturer,
Manufacturer,

Address
Address
Address
Address
Address
Address
Address
Address
Address

Address
Address
Address
Address
Address
Address
Address
Address
Address

Address;
Address;
Address;
Address;
Address;
Address;
Address;
Address;
Address;

1)
2)
3)
4)
5)
6)
7)
8)
9)

API
API
API
API
API
API
API
API
API

Supplier,
Supplier,
Supplier,
Supplier,
Supplier,
Supplier,
Supplier,
Supplier,
Supplier,

Ad
Ad
Ad
Ad
Ad
Ad
Ad
Ad
Ad

10) API Manufacturer, Address Address Address;


11) API Manufacturer, Address Address Address;
12) API Manufacturer, Address Address Address;

10) API Supplier, A


11) API Supplier, A
12) API Supplier, A

PROCEED

PROCEED

in this form, and to provide complete


compliance with the rules and regulations of the
tice (GMP), Good Distribution and Storage Practice
e (GLP). Further, the undersigned agree to grant
ed with this application.

nt

6.1.5 Mailing Address

GONZALES ST., BIASONG, DIPOLOG


CITY

6.1.6.0 E-mail Address:


robert.dampor@yahoo.com

6.1.6.1 Contact Detail 1


Landline: NA
6.1.6.2 Contact Detail 2
Mobile: ###
6.1.6.3 Contact Detail 3
Fax: NA
6.2.5 Mailing Address
GONZALES ST., BIASONG, DIPOLOG
CITY

6.2.6.0 E-mail Address:


NA

6.2.6.1 Contact Detail 1


Landline: NA

on

6.2.6.2 Contact Detail 2


Mobile: 9161479762
6.2.6.3 Contact Detail 3
Fax: NA

nes.

s in the future including

horized personnel;

any way be connected with any

e registered with the Food and

y discrepancy, prejudicial contents


gainst the undersigned and/or the

f location, change of ownership,


in activity, change in key

at we assume primary

ves at any reasonable time and

ownership, or any other

EVOCATION of the License to

rwise known as the Food and Drug

thers, and prays that this

NT AND PRIVATE

__

Place Issued

_________________________

_________________________

ed to me that the same is their

the
, and
s

Use this space to explain how the lot code


used on the product label is correctly
interpreted

Use this space to explain how the lot code


used on the product label is correctly
interpreted

plier,
plier,
plier,
plier,
plier,
plier,
plier,
plier,
plier,

Address
Address
Address
Address
Address
Address
Address
Address
Address

Address
Address
Address
Address
Address
Address
Address
Address
Address

Address;
Address;
Address;
Address;
Address;
Address;
Address;
Address;
Address;

pplier, Address Address Address;


pplier, Address Address Address;
pplier, Address Address Address;

Department of Health
Food and Drug Administration

APPLICATION
FORM
1 1 0 0 0 0 0 SOURCES & CLIENTS:

APPLICATION FORM STATUS:


GENERAL INFORMATION: PRO
ESTABLISHMENT INFORMATION: PRO
PRODUCT INFORMATION: PRO
SUPPORTING INFORMATION: PRO
APPLICANT INFORMATION: PRO
PAYMENT INFORMATION:
GENERAL INFORMATION

1
1
1
1
1

1.1 Product Center:

Drug

1.2 Authorization:

License to Operate

1
0
0
1

PRO 1

Document Tracking Number


0
1
1

0
1

1
1

0
1
Description (Optional):
0
2 ESTABLISHMENT INFORMATION
1.4 Primary Activity:
2.1 Name of Establishment

Wholes

DUC-Z PHARMACEUTICALS
1.3 Type:

Renewal
2.3 Tax Identification Number:
2.4 Office Address

TURNED INITIAL

0 GONZALES ST., BIASONG, DIPOLOG CITY


30-Dec-1899 2.5 Warehouse Address

GONZALES ST., BIASONG, DIPOLOG CITY


0
30-Dec-1899
2.7.0
2.7.1
2.7.2
0 2.7.3

0
0

E-mail Address:
Contact Detail 1
Contact Detail 2
Contact Detail 3

robert.dampor
Landline:
Mobile:
Fax:

0
1
0

1
0
1

0
0
0

1
1
Type of Amendment:
Source: Add/ Delete FAL

Page 40 of 78

1
Other Amendments
License to Operate

1
TRU 1

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Department of Health
Food and Drug Administration
Source: Change of BuFAL
Change of Importer/ DFAL
Product Registration FAL
License to Operate TRU

0
0
0
1
1

0
APPLICATION FORM
0 1

FAL
Reclassification
0 Activity: Additional
FAL
FAL
Finished Product
FAL
Raw Material
Free Sale, Certificate FAL
Pharmaceutical Product
FAL
Export Certificate
FAL
FAL
Product Line

ORDER OF PAYMENT
Amount Due:
Fee :
Legal Research Fee :
Surcharge :
OR Number :
Date Paid:
Computation Valid Until:
6 APPLICANT INFORMATION

0
0
0
0
0
0

Php

1
1

46100
10000
100
36000

This is the application form. Without the


42280 declaration form, this application may b

The undersigned attest to have provided true and complete information in this form, and to provide com
the time of submission. The undersigned agree to strict compliance with the rules and regulations of the
Administration (FDA), including Good Manufacturing Practice (GMP), Good Distribution and Storage Pract
Pharmacy Practice (GPP), and/or Good Laboratory Practice (GLP). Further, the undersigned agree to gran
verify the truthfulness of the information provided with this application.

6.1 APPROVING AUTHORITY

6.1.5 Mailing Addr

Signature
6.1.1.0 Family Na DAMPOR
6.1.1.1 First Name(ROBERT TITO
Latest photo of applicant
6.1.2 Designation:
6.1.3 Tax ID Number:
6.1.4.0 Type of Gov't ID:
6.1.4.1 ID Number:
6.1.4.2 Date Expiry:
6.2 APPLICANT

6.1.1.2 Middle Na IBAEZ


Owner/ General Manager/ President
403-376-459
Social Security System
100-909-2063
NA

GONZALES ST., BIA


6.1.6.0 E-mail Add
robert.dampor@ya
6.1.6.1 Contact De
Landline:
6.1.6.2 Contact De
Mobile:
6.1.6.3 Contact De
Fax:

6.2.5 Mailing Addr

Signature
6.2.2.0 Family Na AGOT
6.2.2.1 First Name(LILIA

GONZALES ST., BIA


6.2.6.0 E-mail Add

Latest photo of applicant


Page 41 of 78

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Department of Health
Food and Drug Administration
Latest photo of applicant
6.2.2 Designation:
6.2.3 Tax ID Number:
6.2.4.0 Type of Gov't ID:
6.2.4.1 ID Number:
6.2.4.2 Date Expiry:

Page 42 of 78

APPLICATION
FORM
6.2.2.2 Middle Na TACLOB
Company Pharmacist
204-557-030-000
Professional Regulatory Commission

329986351.xlsx

NA
6.2.6.1 Contact De
Landline:
6.2.6.2 Contact De
Mobile:
20092 6.2.6.3 Contact De
42213 Fax:

09/17/2016 15:44:53

Department of Health
Food and Drug Administration
License to Operate

APPLICATION FORM

This form is the second page of a two-page application form for licensing by the Food and Drug Admi

PETITION

I/we am/are duly authorized to affirm the following declaration on behalf of the Company:

I. The said establishment shall be open for business hours under the supervision of PRC registered profe

II. The pharmacist and other allied health professionals, upon and during employment in this establishm

III. The approved and valid License to Operate shall be displayed in a conspicuous place of the establish

IV. To change the business name of the establishment in the event that there is a similar or same name

V. The attached electronic copy of files/documents/information of the LTO application are the exact dupli
VI. If applying for automatic renewal:
a. Have filed the application before expiry date;
b. Have paid the renewal fee prior its expiry date;

c. That there are no unapproved changes or variations whatsoever in the establishment since the las

VII. The products we manufacture, distribute or sell are registered or to be registered with FDA prior to d

VIII. The establishment whether for initial, renewal or automatic renewal, is still subject to inspection by

IX. Non-compliance
with the requirements329986351.xlsx
and/or failure to give notice to the FDA
of the change
in busin
Page
43 of 78
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Department of Health
Food and Drug Administration

APPLICATION FORM

IX. Non-compliance with the requirements and/or failure to give notice to the FDA of the change in busin

X. Any violation of the above provisions and rules and regulations will automatically be subject to the SU

XI. I/We make this declaration in full knowledge and awareness of Republic Act No. 3720, as amended b

WHEREFORE, the undersigned confirm the truth of our declaration and awareness of the foregoing duties

WAIVER

I HEREBY GRANT AUTHORITY TO THE FOOD AND DRUG ADMINISTRATION TO VERIFY THE AUTHENTICITY O
ACKNOWLEDGEMENT

SUBSCRIBED AND SWORN TO BEFORE ME this _______ day of _________________ 20__


_______________________________________________________, Philippines, personally appeared the following :
Name and Signature

1) DAMPOR ROBERT TITO

2)

Known to me and to me known to be the same persons who execute the foregoing instrument consistin

Doc. No. : _____________________________


Page No. : ____________________________
Book No. : ____________________________
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Department of Health
Food and Drug Administration

APPLICATION FORM

Book No. : ____________________________

Series of : _____________________________

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Department of Health
Food and Drug Administration

APPLICATION FORM

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Department of Health
Food and Drug Administration

APPLICATION FORM

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Food and Drug Administration

APPLICATION FORM

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Food and Drug Administration

APPLICATION FORM

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Department of Health
Food and Drug Administration

APPLICATION FORM

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Department of Health
Food and Drug Administration

APPLICATION
FORM
4 SUPPORTING INFORMATION

Add or Del

0
1
1
1 PRO

Wholesaler
1

403-376-459-000
2.5.1 RegioIX
1

OG CITY
2.6.1 RegioIX
1

OG CITY
1
1
1

dampor@yahoo.com
e:
NA
9177262049
NA

1
1
1

1
1

Drug
Food

0
0

1
1
1
1
1
1

HUHS
Device

None

0
1

0
0

1
0
0
0
0

Page 51 of 78

1
1
1

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Department of Health
Food and Drug Administration
0
0
Php

APPLICATION FORM00 1
None

1
1
0

1
1

hout the appropriate petition or


n may be rejected.

1
1
1
1

0
01
None

1
0
1

de complete requirements at
s of the Food and Drug
ge Practice (GDSP), Good
to grant authority to the FDA to

ng Address

1
1
1
1

0
01

ST., BIASONG, DIPOLOG CITY


mail Address:
mpor@yahoo.com
ntact Detail 1
NA
ntact Detail 2
9177262049
ntact Detail 3
NA

None

1
0
1

ng Address

1
1
1
1

0
01
None

1
0
1

ST., BIASONG, DIPOLOG CITY


mail Address:

Page 52 of 78

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Department of Health
Food and Drug Administration

APPLICATION FORM

ntact Detail 1
NA
ntact Detail 2

1
1
1
1

9161479762

ntact Detail 3
NA

Page 53 of 78

0
01

329986351.xlsx

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Department of Health
Food and Drug Administration

APPLICATION FORM

ug Administration of the Philippines.

ed professional (if applicable) or authorized personnel;

ablishment, is/are not and will not in any way be connected with any other FDA regulated establishment (if a

stablishment;

e name registered with the Food and Drug Administration or if it rules later that it is misleading;

ct duplicate of the hard copy and, any discrepancy/ prejudicial contents or wilful misrepresentation on any o

e the last renewal of LTO specifically but not limited to change of location, change of ownership, change of bu

rior to distribiution or selling;

tion by FDAs authorized representatives at any reasonable time and undertake to respond and cooperate fu

in business
business name, ownership,
or any other circumstances in relation
to the approval
of thi
Page 54 address,
of 78
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Department of Health
Food and Drug Administration

APPLICATION FORM

in business address, business name, ownership, or any other circumstances in relation to the approval of thi

o the SUSPENSION/ CANCELLATION/ REVOCATION of the License to Operate.

ended by Republic Act no. 9711, otherwise known as the Food and Drug Administration Act of 2009, other a

g duties and responsibilities among others, and prays that this application for License to Operate be granted

TICITY OF ALL THE DOCUMENTS SUBMITTED FROM BOTH GOVERNMENT AND PRIVATE RESOURCES.

___ 20________ at ______________________________

owing :
Identification Number

Date Issued

Place Issued

_________________________

___________

__________________

_________________________

___________

__________________

consisting of 2 pages including the application form, and they acknowledged to me that the same is their fre

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Department of Health
Food and Drug Administration

APPLICATION FORM

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APPLICATION FORM

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Department of Health
Food and Drug Administration
1
APPLICATION FORM
1
PR
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1D
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OC1
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Food and Drug Administration
0
1
APPLICATION
FORM
01
1
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0
1

1
1
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Food and Drug Administration

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0
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1
1
1
1
1

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Department of Health
Food and Drug Administration

APPLICATION FORM

hment (if applicable);

n on any of the data therein shall be a ground for disapproval of

hange of business name, change of registered pharmacist, change

ooperate fully with the FDA with regard to any subsequent post-ma

roval
of this
is a ground for delisting
of the License to
Page
65 application
of 78
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Food and Drug Administration

APPLICATION FORM

roval of this application is a ground for delisting of the License to

09, other allied laws and their implementing rules and regulations

be granted after compliance with the Food and Drug Administrati

S.

ssued

_______________________

_______________________

is their free and voluntary act and deed. WITNESS MY HAND AND

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