Republic of the Philippines

Department of Health
CENTER FOR HEALTH DEVELOPMENT 3
Government Center, Maimpis, City of San Fernando (P)
(045) 961-2099

NOTICE OF CHANGE OF PHARMACIST (___)

NOTICE OF ADDITIONAL PHARMACIST (___)

Name of Establishment : _____________________________________________________

Address of Establishment : _____________________________________________________
Owner : ____________________________ Tel. No. _________________
LTO Number : ____________________________ Expiry Date ______________
Name of Outgoing Pharmacist : _____________________________________________________
Date Resigned : _______________________
Name of Pharmacist In-Charge: ____________________________________________________
(PRC Registered Name)

____________________________________________________
(Maiden or Married Name Different from Above)
Service Begun __________________________
PRC ID No. ____________________ Date of Issue _________________ Validity _____________
PTR No. _________________ Issued at ___________________________ on __________________
Residential Address ________________________________________________________________
_____________________________________ Tel. No. ____________________
We certify to the truth of the foregoing and further certify:
1. That that Pharmacist In-Charge will supervise the operation of the above mentioned
establishment from _______________a.m. to ________________ p.m.
2. That I, the Pharmacist In-Charge, am not and will not be in anyway connected with any
drug or similar establishment / outlet.
It is understood that the drugstore shall be closed every time the registered pharmacist is out
or is on vacation / rest day.

______________________________
OWNER
Res. Cert. No. _________________________
Issued at _________________________
On _________________________
____________________________
PHARMACIST - IN – CHARGE
Res. Cert. No. _____________________________
Issued at ____________________________
On ____________________________

Date Filed : _____________________________

SUBSCRIBED AND SWORN TO BEFORE ME THIS _____________ DAY OF _____________

AT ______________________________________.

__________________________________
Notary Public

Attached the photocopy of the following documents:

a. 2 (2X2 ID Picture), Board Certificate, PRC ID, Current PTR
b. Certificate of Attendance to FDA sponsored seminar
c. Duly noted resignation letter of Outgoing & Incoming Pharmacist from previous employer