7 Republic ofthe Philippines y Depatneat of Health Ms FOOD AND DRUG ADMINISTRATION Fog aetran agin Finest Comorate City Alabang, Muntinlupa City QWP-007-050-01- ANNEX 01-01 PETITION FORM REGULATION DIVISION 1- FOOD SECTION a (Owner) In the matter of Petition of (Name of Owner and/or Incorporator/ to open the license to operate (LTO) of a Food Distributor more particular as a: ()Importer_ ( ) Exporter ( ) Wholesaler PETITION COMES NOW the undersigned petitioner unto the Food and Drug Administration, Department of Health (DOH), Alabang City of Muntinlupa, respectfully alleges: FIRST- That the petitioner is of legal age, married/single, Filipino citizen and residing at SECOND- That he/she desires to open a food (Classification) establishment particularly a/an of food and food product to be located at (Office Address) is _ with warehouse located at and shall be known as (Business Name) mi THIRD- That the said establishment, with a capitalinvestment of Php. is owned by (Corporate Name / owner) _— with postal address at and — with contact no, fi FOURTH- That the petitioner hereby agrees to change the business name of corporate name of the establishment in the event that there is a similar or same name registered with the Food and Drug Administration or if it rules later that it is misleading; FIFTH- That the petitioner will be held liable for not informing FDA of any changes in the status of business such as ownership, transfer of office/warehouse address, activities and suppliers/sources. WHEREFORE, the petitioner respectfully prays that he/she be granted the License to operate said establishment after inspection, thereof and after compliance with the requirements, rules and regulations of the Food and Drug Admi Metro Manila, Philippines ope | Respectfully submitted: (Signature) PRINTED NAME PETITIONER SUBSCRIBED AND SWORN to before me this __ day of _ 20__Affiant exhibited to me his/her Residence Certificate No. issued at on B0mEe NOTARY PUBLIC