02 d Joint Affidavit Undertaking

Republic of the Philippines Department of Health Food and Drug Administration CENTER FOR DEVICE REGULATION, RADIATION HEALTH, AND RESEARCH (former name : Bureau of Healt De!"#e$ an% Te#nolo&' Te#nolo&' LICENSING AND REGISTRATION DIVISION 

CDRRHR-2-L-02D Revision o! 2 Date "ffective# $% April 20

%$)OINT AFFIDAV AFFIDAVIT OF UNDERTA*ING &'() AFF(DA*() 'F +D"R)A,(

 ..............................  .............................. 1PRC Registered ame

PHAR/AC()-(-CHAR" PHAR/AC()-(-CHAR" 3ith PRC Registration o! ...............  (ssued on...............................  P)R '! ...............................  ............................... 

 ......................................   ..................................... .  1/aiden or /aiden ame different from above of legal age4 single5married4 and a resident of .................................. .................................. and..........   .....................................  .................. ...................................... ....................................... .............................  .........  o6ner of................................... of...................................................... ...................................... ......................  ...  1/edical Device "stablishment located located at .......... ............... .......... .......... ......... ......... .......... .......... ......... ......... .......... .......... ..... of legal age and resident of................................................. after having been s6orn in accordance 6ith la64 hereb7 declare# FIRS FIRST T + )hat 6e are full7 a6are of the provisions of the Pharmac7 La64 the Foods4 Drugs4 Devices4 and Cosmetics Act4 the enerics Act of $8994 that 6e are a6are of the specific re:uirements that the 'peration of....... of............ .......... .......... ......... ......... .......... .......... ......... ......... .......... .......... .......... .......... ......... ........sh ....shall all be under the (//"D(A)" AD P"R'AL +P"R*((' of the Pharmacist-(n-Charge4 the business hours  being from .......A/ to ........ ........ P/; SECOND  < that 6e agree to change the business name if there is alread7 a validl7 registered name similar si milar to our business name; THIRD THIR D  < that 6e shall displa7 our approved License to 'perate 1L)' 1L)' in a conspicuous place of our  establishments; FOURTH - that 6e shall notif7 FDA in case of an7 change1s in the circumstances of our application for a License to 'perate4 including but not limited to change1s of location4 change of o6nership4 change of   pharmacist-in-charge4 and change in medical device products; FIFTH  and that (4 the pharmacist-in-charge4 am not and 6ill not be in an7 6a7 connected 6ith an7 drug or  similar establishment5outlet; -E e=ecute this &oint Affidavit of +nderta>ing to confirm the truth of our declaration and our a6areness of the fore going duties and responsibilities among others! -ITNESS -HEREOF4 -E hereunto affi= our signature this .................da7 of ............. 20  .......!!  ..................................  .................. ................ ...................................  ...................................  '3"R PHAR/AC() Res! Cert! o! ...................... ...................... Res! Cert! o! ........................  ........................  (ssued on .................... .......................... ...... (ssued on ...........................  ...........................  at ............................... ............................... at .................................  ................................. 

+?CR(?"D AD 3'R )' /" )H( ............. da7 of ...............20 .......!  ............................   .................. ..........   ')AR@  ')AR@ P+?L(C +ntil December $4 20