CHECKLIST OF REQUIREMENTS FOR DRUGSTORE / CHINESE DRUGSTORE / HOSPITAL PHARMACY / RETAIL OUTLET FOR NON-PRESCRIPTION DRUGS

General Requirements: _________ _________ _________ _________ (ALL FORMS MUST BE ACCOMPLISHED IN TRIPLICATE)

Notarized Accomplished Petition Form / Joint Affidavit of Undertaking Tentative list of products using generic names and brand names, if any Floor area, not less than 15 square meters Reference Books Philippine National Drug Formulary R.A. 3720 otherwise known as Food, Drugs and Devices and Cosmetic Act R.A. 6675, Generics Act of 1988 and relevant implementing rules and regulations R.A. 5921, Pharmacy Law as amended and relevant implementing rules and regulations R.A. 8203, Special Law on Counterfeit Drugs.

Any of the following Reference Books: United States Pharmacopoeia / National Formulary (USP-NF) latest edition Remingtons Pharmaceutical Sciences (latest edition) Goodman and Gillman Pharmacological Basis of Therapeutics (latest edition)

_________ Record Books duly registered with BFAD (Prescription Book) _________ Generic, White, and Red Labels _________ Dry Seal or rubber stamp of outlets _________ Photocopy of Pharmacists Registration Board Certificate, Valid PRC-ID, Valid PTR, 2x2 ID Picture and Certificate of Attendance of owner/pharmacist to any BFAD Sponsored / Accredited Seminar on Licensing of Establishments and outlets _________ If Single proprietorship, Certificate of Business Name Registration with the Bureau of Trade Regulation and Consumer Protection (BTRCP) formerly known as Bureau of Domestic Trade. _________ If Corporation/Partnership, copy of Registration with SEC and Articles of Incorporation or Partnership. _________ Notarized valid Contract of Lease of the space/building occupied, if the applicant does not own it. _________ Picture of Drugstore with signboard _________ Opening Fee of P1,000.00 (Based on A.O. 50 series of 2001)

Additional Requirements: _________ Location Plan / Site (size, location, immediate environment, type of building) _________ Floor Plan with dimensions (Lay-out of the premises)

Changes in Circumstances: _________ Official letter re: Change of Address / Owner / Business Name and/or etc. _________ Surrender original / old License to Operate and COC / CTR _________ Deed of Sale / Transfer of Rights in case of change of ownership _________ Notarized Affidavit of Pharmacist in case of change of pharmacist

Republic of the Philippines Bureau of Food and Drugs Department of Health Center for Health Development No. XI J.P. Laurel Avenue, Davao City Tel. (082) 305-1902 Fax (082) 221-6320 IN THE MATTER OF PETITION OF: ________________________________________________ TO OPEN A DRUG / COSMETIC ESTABLISHMENT, MORE PARTICULARLY AS A: ______ Retail Drugstore ______ Chinese Drugstore ______ Hospital Pharmacy ______ Retail Outlet for Non-Prescription Drugs (RONPD)

PETITION COMES NOW the undersigned petitioner unto the Bureau of Food and Drugs, Department of Health, Alabang, City of Muntinlupa, Metro Manila, respectfully alleges; FIRST That the petitioner is of legal age, married/single, Filipino citizen and residing at _____________________________________________________________________________________; SECOND That the petitioner desires to open a Drug / Cosmetic establishment, more particularly, a _____________________________ to be located at ___________________________________ and shall be known as _________________________________________________ with Tel.No. _______________; THIRD - 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 ____________________________ ; FOURTH That __________________________________ is the owner of said establishment with the postal address at ___________________________________________________________________ ; FIFTH That the amount of capital invested for said establishment P ______________________; 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 Bureau of Food and Drugs or if it rules later that it is misleading. WHEREFORE, the petitioner respectfully prays that she/he be granted License to Operate a drug / cosmetic / medical device establishment after inspection thereof and after compliance with the Bureau of Food and Drugs requirements, rules and regulations. Davao City, Philippines, _______________________________ , 20 _____. The undersigned, as owner of the establishment, hereby declares under oath that he conforms to the declaration of the petitioner pharmacist. Owner: ___________________________________ Signature over Printed Name Address: ___________________________________ Residence Certificate No._______________________ Issued on: _______________ at _________________ Telephone / Cellphone No.______________________

Respectfully submitted: ______________________________________ Signature over Printed Name of Pharmacist Address: _______________________________ Residence Certificate No. _________________ Issued on: _____________ at ______________ Telephone / Cellphone No.: ________________

SUBSCRIBED AND SWORN to before me this __________ day of ____________, 20 ____. Affiant exhibited to me his/her Residence Certificate(s), the date of which are indicated below his/her Respective name(s) on page hereof.

Documentary Stamps

__________________________________ Notary Public

Doc. No. ______________ Page No. ______________ Book No. ______________ Series of ______________

INSTRUCTIONS 1. For single proprietorship, attach CERTIFICATE OF BUSINESS NAME REGISTRATION from the Department of Trade and Industry (DTI). For corporation, partnership, or other juridical person, attach CERTIFICATE OF REGISTRATION with the Securities and Exchange Commission (SEC), together with a copy of Articles of Incorporation and By-Laws. If the applicant is an alien, the petition must be accompanied by an authenticated copy of the CERTIFICATE OF ALIEN REGISTRATION. 2. All drugs and cosmetic products, prior to their introduction into the domestic commerce, must first be registered with BFAD. 3. Application must be accompanied by BFAD-LSS Form No. 6 re: Clearance of Name, for purpose of misbranding provisions of R.A. 3720. 4. For other requirements, consult BFAD License Inspector.

JOINT AFFIDAVIT OF UNDERTAKING

I, ____________________________________________________, Pharmacist-In-Charge with
(Family Name, First Name, Middle Name)

PRC Registration Number : __________________ Issued on : _______________________________ PTR No. : _______________________________ of legal age, single/married and a resident of ________________________________________ ____________________________________________________________________________
(Permanent Home Address )

and OWNER of ____________________________________________________________________________

(Name of Company)

located at ___________________________________________________________________
(Address of Company)

of legal age, and a resident of ___________________________________________________ after having been sworn in accordance with law, hereby declares: 1. That we are fully aware of the provisions of Pharmacy Law, the Foods, Drugs, Devices and Cosmetics Acts, the Generics Act of 1988 and that we are aware of the specific requirements that the operation of _______________________ shall be under the IMMEDIATE AND PERSONAL SUPERVISION of the Pharmacist-in-Charge with business hours being from __________ AM to __________ PM; That we agree to change the business name if there is already as validly registered name similar to business name; That we shall display the approved License to Operate in a conspicuous place of my establishment; That we shall notify BFAD in case of any change(s) in the circumstances of our application for a license to operate, including but not limited to change(s) of location, change of pharmacist-in-charge and change in drug products; And that the Pharmacist-in-charge, will not be in any way connected with any other drug or similar establishment/outlet;

2. 3. 4.

5.

WITNESS HEREOF, I hereunto affix our signatures this ________ day of ___________________, 200___.

_______________________________ Owner Res. Cert. No. ___________________ Issued On ______________________ At ____________________________

_______________________________ Pharmacist Res. Cert. No. ____________________ Issued On _______________________ At _____________________________

SUBSCRIBED AND SWORN to me this _______ day of __________________, 200___, at _________________________. _____________________________ NOTARY PUBLIC Until December 31, 20____ Doc. No. ______ Page No. ______ Book No. ______
Documentary Stamps

Series of ______