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Joint Affidavit of Undertaking

The document is a Joint Affidavit of Undertaking submitted to the Food and Drug Administration of the Philippines. It contains the signatures and information of Dr. Melanio V. Lazaro, owner of Maddela District Hospital located in Maddela, Quirino, and Arlene F. Ambre, the Pharmacist-in-Charge with PRC Registration No. 37814. Through this affidavit, Dr. Lazaro and Ms. Ambre declare their awareness of pharmacy laws and regulations, their agreement to notify FDA of any changes to their establishment, and their commitment to operate the hospital pharmacy under Ms. Ambre's immediate and personal supervision.

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Maddela District Hospital
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86 views

Joint Affidavit of Undertaking

The document is a Joint Affidavit of Undertaking submitted to the Food and Drug Administration of the Philippines. It contains the signatures and information of Dr. Melanio V. Lazaro, owner of Maddela District Hospital located in Maddela, Quirino, and Arlene F. Ambre, the Pharmacist-in-Charge with PRC Registration No. 37814. Through this affidavit, Dr. Lazaro and Ms. Ambre declare their awareness of pharmacy laws and regulations, their agreement to notify FDA of any changes to their establishment, and their commitment to operate the hospital pharmacy under Ms. Ambre's immediate and personal supervision.

Uploaded by

Maddela District Hospital
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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FOOD AND DRUG ADMINISTRATION

CENTER FOR DEVICE REGULATION, RADIATION HEALTH AND RESEARCH

LICENSING and REGISTRATION DIVISION

JOINT AFFIDAVIT OF
UNDERTAKING

Document No.:

011-004-L-02D

Revision No.

Date Effective:

6 August 2012

Page:

1 of 1

JOINT AFFIDAVIT OF UNDERTAKING

ARLENE F. AMBRE
(PRC Registered Name)

PHARMACIST-IN-CHARGE
With PRC Registration No. 37814
Issued on FEBRUARY 11, 1997
PTR NO. _______________________________

________________REYES________________
(Maiden or Maiden Name different from above)
of legal age, single/married, and a resident of PONGGO, NAGTIPUNAN, QUIRINO and DR. MELANIO
V. LAZARO
owner of
MADDELA DISTRICT HOSPITAL
(Medical Device Establishment)
located at DIDUYON, MADDELA, QUIRINO of legal age and resident of 85 BONIFACIO STREET
DISTRICT 4, POBLACION, SAN MATEO, ISABELA after having been sworn in accordance with law,
hereby declare:
FIRST - That we are fully aware of the provisions of the Pharmacy Law, the Foods, Drugs, Devices, and
Cosmetics Act, the Generics Act of 1988, that we are aware of the specific requirements that the Operation
of
HOSPITAL PHARMACY
shall be
under the IMMEDIATE AND PERSONAL SUPERVISION of the Pharmacist-In-Charge, the business
hours being from 8:00 AM to 5:00 PM;
SECOND that we agree to change the business name if there is already a validly registered name similar
to our business name;
THIRD that we shall display our approved License to Operate (LTO) in a conspicuous place of our
establishments;
FOURTH - that we shall notify FDA 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 ownership, change of
pharmacist-in-charge, and change in medical device products;
FIFTH and that I, the pharmacist-in-charge, am not and will not be in any way connected with any drug
or similar establishment/outlet;
WE execute this Joint Affidavit of Undertaking to confirm the truth of our declaration and our awareness
of thefore going duties and responsibilities among others.
WITNESS WHEREOF, WE hereunto affix our signature this 2ND day of DECEMBER 20 14
MELANIO V. LAZARO, MD.

OWNER
Res. Cert. No. 34958599
Issued on 09 30 14 RE ISSUE
at MADDELA, QUIRINO

..

ARLENE F. AMBRE

PHARMACIST
Res. Cert. No. 30111955
Issued on 01 13 2014
at NAGTIPUNAN, QUIRINO

SUBSCRIBED AND SWORN TO ME THIS _____________ day of _______________20 _______.


____________________________
NOTARY PUBLIC
Until December 31, 20

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