Republic of the Philippines

City of Batangas

JOINT AFFIDAVIT

We, Felizardo S. Marasigan, single and Rowena K. Vidal, married, of legal ages. Filipinos, and
residing at Taliba, San Luis, Batangas and Roxas Road, Kumintang Ibaba, Batangas City and employed as
hospital administrator and pharmacist, respectively, by Taal Polymedic Hospital and Medical Center of
Diversion Road, Carsuche, Taal, Batangas after having been duly sworn in accordance with the law do
hereby depose and say:

That Taal Polymedic Hospital and Medical Center is a renewal applicant for a PDEA license to
handle the following specified dangerous drugs:

Name of Dangerous Purpose of Handling Projected Annual Suppliers

Drugs (Importation/Exportation/ (Importation/Exportation/
Manufacturer/Repack/Recycle Manufacturer/Distributor/
/ Retail/
Distribute/Retail and Use Lab. Consumption)
Or Research/Use) Choose activity as
Choose activity as appropriate appropriate

Clonazepam (Rivotril) For hospital retail use/Local 1000 tablets Feyler Enterprises
2mg tab x 100’s Purchase Pear l St. Beredo
Village, Alangilan,
Batangas City
Diazepam (Valium) 5mg For hospital retail use/Local 1000 tablets Feyler Enterprises
tab x 100’s Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City

Diazepam (Valium) For hospital retail use/Local 600 ampoules Feyler Enterprises
5mg/ml (2ml) amp x 10’s Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City
Ephedrine amp 50mg/ml For hospital retail use/Local 500 ampoules Feyler Enterprises
x 100’s 1ml Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City
Fentanyl 50mcg/ml (2ml) For hospital retail use/Local 100 ampoules Feyler Enterprises
amp x 10’s Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City
Ketamax (Ketamine) Vial For hospital retail use/Local 50 vials Feyler Enterprises
50mg/ml 1’s 10ml Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City

Midazolam (Dormicum) For hospital retail use/Local 600 ampoules Feyler Enterprises
1mg/ml (5ml) amp Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City
 Morphine tab 10mg x For hospital retail use/Local 600 ampoules Feyler Enterprises
100’s Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City
Morphine tab 30mg x For hospital retail use/Local 500 tablets Feyler Enterprises
100’s Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City
Nalbuphine (Nubain) For hospital retail use/Local 700 ampoules Feyler Enterprises
10mg/ml (1ml) amp x Pear l St. Beredo
100’s Purchase Village, Alangilan,
Batangas City
Phetedine (Demerol) For hospital retail use/Local 100 ampoules Feyler Enterprises
50mg/ml (2ml) amp x 10’s Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City
Phenobarbital (Luminal) For hospital retail use/Local 200 ampoules Feyler Enterprises
130mg/ml (1ml) amp x 5’s Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City
Phenobarbital tab 15 mg For hospital retail use/Local 500 tablets Feyler Enterprises
x 100’s Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City
Phenobarbital tab 30mg x For hospital retail use/Local 500 tablets
100’s Feyler Enterprises
Purchase Pear l St. Beredo
Village, Alangilan,
Batangas City
Phenobarbital tab 60 mg For hospital retail use/Local 500 tablets Feyler Enterprises
x 100’s Pear l St. Beredo
Purchase Village, Alangilan,
Batangas City

That the above cited dangerous drug/s shall be solely used for the legitimate purpose
governing the nature of the applicant’s legitimate existence, and in case will it be diverted to illegal
purposes.

That our PDEA license expired on February 21, 2020 due to Taal volcano eruption, non-
issuance of business permit and change of hospital administrator. We don’t have any transaction
after our license expired. As a preventive measure we will see to it that our dues will post on
calendar and ensure all the proper documents is updated. At a corrective measure we will renew
our license 3 months ahead of time. We will assure that lapses will not occur again, assurance of
repetition.

That for and in behalf of our establishment and by virtue of this Affidavit we hereby bind
ourselves to all the provisions of: Republic Act 9165 otherwise known as the “Comprehensive
Dangerous Drug Act of 2002, and other implementing Rules and Regulations and assuring that
such law and regulations shall be faithfully complied with:
 That, we are executing this Affidavit to attest the truth of the foregoing facts, and for
whatever Legal intent and purpose it may serve;

IN WITNESS HEREOF, we have here unto set our hands this ______________________ at
Taal, Batangas City, Philippines.

Felizardo S. Marasigan Rowena K. Vidal

Hospital Administrator PDEA-Registered Pharmacist

SUBSCRIBED AND SWORN to before me this ______________ at Batangas City, Philippines. Affiants
personally exhibiting their SSS ID # 33-2602256-5 and Pharmacist PRC ID # 0042901
Wilkins Villanueva
The Director General
Philippine Drug Enforcement agency
PDEA Bldg. NIA Northside Road, National Government Center,
Brgy. Pinyahan, Quezon City

Attention: Director III Agnes Mandap, RPh, MBA, MGM

The Director, Compliance Service

Subject: Letter of Authorization

Dear Sir / Madam,

As Hospital Administrator, I hereby delegate my authority to handle Dangerous drugs / Dangerous

drug preparation / preparations containing Table 1 controlled chemicals for the establishment to
Rowena K. Vidal, Pharmacist.

As such she is authorized to sign for me and my behalf of the company in matters / transactions
pertaining to the above mentioned preparations. Likewise she will be responsible for its
monitoring, safekeeping, recording and reporting to the Compliance Service, Philippine Drug
Enforcement Agency.

In relation, Enclosed herewith is the picture, specimen signature, joint affidavit, NBI clarance, PRC,
PTR and TIN of Rowena K. Vidal.

Yours Truly,

Felizardo S. Marasigan
Hospital Administrator

Felizardo S. Marasigan Rowena K. Vidal

Hospital Administrator PDEA-Registered Pharmacist