Republic of the Philippines Department of Health

Department of Health Food and Drug Administration

Food and Drug Administration CENTER FOR DEVICE REGULATION, RADIATION HEALTH, AND RESEARCH
CENTER FOR DEVICE REGULATION, RADIATION HEALTH, AND RESEARCH (former name : Bureau of Health Devices and Technology)
(former name : Bureau of Health Devices and Technology) LICENSING AND REGISTRATION DIVISION
LICENSING AND REGISTRATION DIVISION CDRRHR-2-L-04C
CDRRHR-2-L-04C Revision No. 2
Revision No. 2 Date Effective: 15 April 2015
Date Effective: 15 April 2015

DATE: ____________________ CDRRHR-_____________________

DATE: ____________________ CDRRHR-_____________________ Company Name: _____________________________________________________________
Company Name: _____________________________________________________________ Address/Tel No.______________________________________________________________
Address/Tel No.______________________________________________________________ Owner: _____________________________________________________________________
Owner: _____________________________________________________________________ Name of Pharmacist: __________________________________________________________
Name of Pharmacist: __________________________________________________________ Classification: _____________ LTO No.: _____________________ Validity: ___________
Classification: _____________ LTO No.: _____________________ Validity: ___________
TYPE of REQUEST
TYPE of REQUEST ( ) Opening/ Change of Ownership
( ) Opening/ Change of Ownership ( ) Renewal for ______year(s)
( ) Renewal for ______year(s) ( ) Reissuance for lost LTO
( ) Reissuance for lost LTO ( ) Amendment of LTO
( ) Amendment of LTO  Additional Class/Reclassification
 Additional Class/Reclassification  Change of Business name
 Change of Business name  Transfer of Location
 Transfer of Location  Addition/deletion of Source(s)/Manufacturer(s)
 Addition/deletion of Source(s)/Manufacturer(s)  Change of Business Name
 Change of Business Name  Change of address of Supplier(s)/Manufacturer(s)
 Change of address of Supplier(s)/Manufacturer(s) ( ) Certificate CGMP/LTO Exemption
( ) Certificate CGMP/LTO Exemption ( ) Others: _________________________________
( ) Others: _________________________________

PAYMENT
PAYMENT
Amount Due: ₱ _____________________ OR No. : _________________
Amount Due: ₱ _____________________ OR No. : _________________ Legal Research Fee (1%):_______________
Legal Research Fee (1%):_______________ Surcharge ___% : __________________ Date Issued : _________________
Surcharge ___% : __________________ Date Issued : _________________

TOTAL AMOUNT : ₱ ________________ [ ] Cash [ ] Check

TOTAL AMOUNT : ₱ ________________ [ ] Cash [ ] Check
Assessed by: Approved by :
Assessed by: Approved by :
_____________________ ___________________________
_____________________ ___________________________ EVALUATOR CASHIER
EVALUATOR CASHIER

Republic of the Philippines