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Petition Form

FDA petition form except for NCR and Region 4A

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Department of Health
FOOD AND DRUG ADMINISTRATION
Filinvest Corporate City
Alabang, City of Muntinlupa

CENTER FOR COSMETICS REGULATION AND RESEARCH
ANNEX C
IN THE MATTER OF PETITION OF:
_______________________________________________
(Name of Owner/Incorporator/Authorized Representative)

2x2
Picture
(Owner)

TO OPEN A HOUSEHOLD/URBAN HAZARDOUS SUBSTANCES ESTABLISHMENT PARTICULARLY :

( ) MANUFACTURER

( ) TRADER

( ) DISTRIBUTOR

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 an HUHS 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
( ) Incorporator
( ) Authorized Representative of the Establishment;
FOURTH – 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;
FIFTH – That the petitioner will be held liable for not informing FDA of any changes in the status of business such as
ownership, transfer of office/warehouse address, activities and suppliers/sources;
SIXTH – That the amount of Capital invested for said establishment is Php ________________________; and
WHEREFORE, the petitioner respectfully prays that he/she be granted a License to Operate as a HUHS establishment after
inspection thereof and after compliance with the requirements, rules and regulations of the Food and Drug Administration.
_____________, Philippines __________________, 20 _____.
(City,Province)
(DD/MM)
Respectfully submitted by:
___________________________________________________
SIGNATURE OVER PRINTED NAME OF PETITIONER
Contact Number/s:___________________________________
Email Address:______________________________________
VERIFICATION
Petitioner after having sworn in accordance wit 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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