FM-CSVlrd-05

(Date)

The Director General

Philippine Drug Enforcement Agency
Nat’l Gov’t Center, Brgy. Pinyahan,
Diliman, Quezon City

Attention: The Director, Compliance Service

Subject: Letter of Authorization

Dear Sir:

As the (head/owner/GM/BM) of (company/ establishment), I hereby delegate my

authority to handle dangerous drugs / dangerous drug preparations / preparations
containing Table I controlled chemicals in favor of our drug establishment to
(name), (designation). As such, (he/she) is authorized to sign for and in behalf of the
company in matters/transactions pertaining to the above-mentioned preparations.
Likewise (he/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
Clearance, PRC, PTR and TIN of (name of authorized pharmacist)

Very truly yours,

(Printed Name/ Signature and Designation of Owner/Head/GM/BM )

2” x 2” ID Picture 2” x 2” ID Picture
with signature with signature
(taken not later than 1 (taken not later than 1
month from date of month from date of
application) application)

Owner/Head/GM/BM Authorized Pharmacist

Rev_0_April 30, 2018