Drug Establishment Registration Form

1. Establishment

Name*

Street Address*

City

State

Country

Postal Code

FDA Registration Number

DUNS Number

2. Establishment Contact

Contact Person Name*

Job Title*

Mailing Address*

City*

State*

Country*

Postal Code*

E-mail*

Tel Number*

3. Type of Operation

Manufacture

Repack

Relabel

API Manufacture

Private Label Distribution

Brand Owner

Analytical Lab

Sterilize

Other (explain)

4. Drug Status

OTC

Prescription

API

Veterinary

Homeopathic

 

5. Additional Information

Drug Name

Active Ingrediant 1

Assay Value / %

Active Ingrediant 2

Assay Value / %

Submitter Name:

Job Title:

Submitter E-mail: