企业授权书的申请表
Request for Letter of Authorization (LOA)
提示：LOA正常处理时间是每周三/周五，处理后大约3-5个工作日内客户可以收到，但BASF 的LOA处理周期是每周二，且不可以加急，一般2周左右客户可以收到。
运宏业务员姓名*
Name of Yunhong salesman*
Name of Yunhong salesman*
LOA 类别*
辅料商品名称和规格型号*
Product Name and Specification*
Product Name and Specification*
登记号*
Registration Number*
Registration Number*
- CDE 登记号 CDE No.
- DMF 登记号 DMF No.
药品制剂申报类型*
Drug Product Submission Type*
Drug Product Submission Type*
- 新申请 New Submission
- 变更/补充申请 Variation/Submission of Changes
- 发补/补充资料Reponse to Deficiency Letter
药品制剂名称*
Drug Product Name*
Drug Product Name*
给药途径*
Administration route*
Administration route*
- 口服 Oral
- 吸入 Inhalation
- 注射 Injection
- 其他 ，请注明others, pls indicate here
预计递交时间*
Anticipated Date of Submission*
Anticipated Date of Submission*
*此类信息用来跟踪发出的授权书是否用于药品制剂申报，并确保提供更新的法规支持。
*This information is required to track which LOA is actually used in an application field and to assure that regulatory updates are provided.
*This information is required to track which LOA is actually used in an application field and to assure that regulatory updates are provided.
药品上市许可人名称(显示在授权书上)*
Applicant(To be listed on LOA)*
中文:
英文:
联系人*
Contact Person*
Contact Person*
地址和邮编*
Address and Post code*
Address and Post code*
电话*
Phone*
Phone*
电子邮件*
E-mail*
E-mail*
**当上述登记的产品发生任何法规变更时，我们将按此地址通知您。如您填写的地址有变化请务必通知我司，否则您 将可能无法收到变更通知。
**This is the address to which notification of any regulatory changes to registration will be sent. You are required to inform us about any change in the address. Failure to do so may result in change notification being undeliverable.
**This is the address to which notification of any regulatory changes to registration will be sent. You are required to inform us about any change in the address. Failure to do so may result in change notification being undeliverable.
申请公司*
Requested by*
Requested by*
联系人*
Contact Person*
Contact Person*
授权书寄送地址和邮编*
The LoA delivery address & post code*
电话*
Phone*
Phone*
电子邮件*
E-mail*
E-mail*
请注明需要几份盖章授权书(默认为1份)*
