Republic of the Philippines

Department of Health
FOOD AND DRUG ADMINISTRATION
Filinvest Corporate City
Alabang, City of Muntinlupa

QWP-008-020-01-Annex-06
IN THE MATTER OF PETITION OF:

_________________________________
TO OPEN A FOOD ESTABLISHMENT
MORE PARTICULARLY AS A:
( ) Manufacturer/Processor
( ) Repacker
( ) Importer
( ) Exporter
x-------------------------------------------------x

P E T I T I O N

COMES NOW the undersigned petitioner unto the Food and Drug Administration, Alabang Muntinlupa City, respectfully alleges:

FIRST – that the petitioner is of legal age, married/single, Filipino Citizen and residing at _______________________________
_________________________________________________________________________________________________________________

SECOND – That he desires to open a food establishment, more particularly as a ________________________________________

________________________________________________________ of food and food products to be located at ______________________
_________________________________________________________________________________________________ and shall be known as
________________________________________________________________________________;

THIRD – That said establishment, with a capital/investment of ₧_____________________________________________ is owned by

__________________________________________________________________________ with postal address at__________________
________________________________________________________________________ and with Tel. No. __________________________

FOURTH - That the petitioner hereby agrees to change the business name or corporate name of the establishment in the event that
there is a similar or name registered with the Food and Drug Administration or if it is rules later that it is misleading.

WHEREFORE, the petitioner respectfully prays that he/she be granted license to operate said establishment after inspection thereof
and after compliance with the Food and Drug Administration requirements, rules and regulations, including but not limited to attached BFAD-
ILD form No. 6, which is made as an integral part of this petition.

Metro Manila, Philippines,__________________________________________________________ 20__________________.

Respectfully submitted:

________________________________
Printed Name of Petitioner

________________________________
Signature

SUBSCRIBE AND SWORN to before me this______________day of __________________________20___________________

Affiant exhibited to me his/her Residence Certificate No.________________________________issued at____________________________
_____________________________________on ___________________________________ 20________________________.

Doc. No.______________
Book No._____________
Page No.______________ _________________________________
Series of______________ Notary Public

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 INFORMATION SHEET
(FOOD MANUFACTURING AND PROCESSING ESTABLISHMENT)

( ) NEW ESTABLISHMENT
( ) PRESENTLY OPERATING

I. Name of Owner:__________________________________________________________________________________________
( ) Single Proprietorship ( ) Corporation
( ) Partnership ( ) Association

II. Name of Establishment:_____________________________________________________________________________________

III. (a) Address of the Food Establishment:_________________________________________________________________________

____________________________________________________________________________________________________________

(b) Postal Address if different from (a)_________________________________________________________________________

____________________________________________________________________________________________________________

(c) Telephone Number(s)____________________________________________________________________________________

IV. List of Food and Food Products to be manufactured; repacked and/or exporter/ imported.

V. List of Equipments and Machineries (For Manufacturer & Repacker Only)

VI. If a License, a State name and address of Licensing Firm:

Name:___________________________________________________________________________________________________
Address:_________________________________________________________________________________________________

VII. Source(s) of raw materials to be used:

(a) Local ( ) Yes ( ) No
(b) Imported ( ) Yes ( ) No

Country of Origin:_________________________________________________

(c) Imported Finished Product in bulk from the repacking:

( ) Yes ( ) No Country of Origin:_________________________________________________

VIII. Personnel: List No. of Technical Employees and their scholastic attainment, who are directly involved in manufacturing
/repacking.

IX. Are the Products produced or manufactured for export ( ) Yes ( ) No or for local domestic consumption? ( ) Yes ( ) No.
If for export, state name of country to which is exported:___________________________________________________________
________________________________________________________________________________________________________

I declared under oath that the foregoing statement composed of two (2) pages are true, correct and complete to
the best of my knowledge and belief.

Respectfully submitted:

___________________________ ______________________________ _________________________

Print Name and Sign Above Title Date

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The electronic copy of this document is controlled. Therefore, all printed versions of this document are uncontrolled copies.