Zonal Change in Address

FDA drug manufacturer form for zonal change in address

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Department of Health
FOOD AND DRUG ADMINISTRATION

CENTER FOR DRUG REGULATION AND RESEARCH
DRUG MANUFACTURER (

) / PACKER (

) / REPACKER (

) TRADER (

)

SELF-ASSESSMENT TOOLKIT FORM
ZONAL CHANGE IN ADDRESS

COMPANY NAME
COMPANY ADDRESS

:
:

NEW ADDRESS
:
OWNER
:
LTO NUMBER
:
VALIDITY
:
Directions:
Fill out the form by ticking the applicable box. Provide remarks on the client’s column when necessary.
Submit in Portable Document Format (pdf) and word format duly signed by the pharmacist/owner.

DOCUMENTARY REQUIREMENTS:

Yes

No

REMARKS
CLIENT

FDA

1. Application Form
Is the integrated application form properly filled out?
Is it duly notarized?
Are the signatories in the application form the authorized
persons as required under the following circumstances?
(a) If single proprietorship – the owner as registered in
DTI (unless there is a different authorized person)
(b) If partnership/corporation – one of the incorporators or
authorized person as indicated in the board resolution
or Secretary’s Certificate
(c) If cooperative – authorized person indicated in the
board resolution or Secretary’s Certificate of the
cooperative
If the signatory is not the owner or one of the incorporators, as
the case may be:

Is there a board resolution or notarized Secretary’s
Certificate clearly identifying the person authorized to sign
for and in behalf of the owner or corporation submitted?




2. Document issued by local municipality as proof of zonal change
 Is the document issued by the local municipality reflects the
zonal change?
 Is the document duly signed by the incumbent local official
or its authorized signatory?
3. Proof of Payment
 Is the payment made according to the required fee?
 Is there a scanned copy of proof of payment (e.g FDA official
receipt, Landbank On-coll validated slip) submitted?
Note: If the following is/are not submitted in the initial application, the said document/s shall be attached:
 Risk Management Plan (RMP) or commitment letter while the official RMP framework from FDA is not yet issued
 GPS Coordinates
NOTE: ADDITIONAL DOCUMENTS MAY BE REQUIRED TO BE SUBMITTED AS DEEMED NECESSARY.
--- To be filled out by client: --Prepared by:
Signature:
Position (Pharmacist / Owner):
Date:

1

--- To be filled out by RFO: --Decision:
Approval
Denial

Remarks:

Clarification

Inspection

Evaluated by:

Decision:
Approval
Clarification
Evaluated by:

Date:

Remarks:

--- To be filled out by CDRR: ---

Date:

2