Application form
different types of statements

Producttype: 1027
Please Note: The fee for an application for a statement is € 56 per individual statement.

Type of statement
Information about the requested type of statement

Requested type of statement *

Please fill in all relevant information

Status of an in vitro diagnostic kit

Name of the in vitro diagnostic kit

Other relevant information

Status of a veterinary medicinal product

Name of the Veterinary Medicinal Product

REG NL number of the Veterinary Medicinal Product

Other relevant information

Status of a manufacturer, importer, wholesaler of a VMP

Name and address manufacturer

Name and address distributor

Name and address importer

Name and address wholesaler

Name of the Veterinary Medicinal Product

REG NL number of the Veterinary Medicinal Product

Other relevant information

Status of a importer / distributor of an API intended for use in a VMP

Name and address importer

Name and address distributor

Country of origin

Country of destination

Full name of material to be imported

Other relevant information

Sanitary information of an active biological substance

Name and address exporter

Name and address consignee

Country of origin

Country of destination

Place of destination

Date and place of shipment

Means of transport

Quantity

Label information

Full name of material to be exported

Sanitary information

Non GMO declaration

Name of the Veterinary Medicinal Product

REG NL number of the Veterinary Medicinal Product

Other relevant information

A contract laboratory (CL) for batch release on VMP

Name and address contract laboratory (CL)

Name and address manufacturer

Licence number

Other

In some cases we issue specially tailored statements on request. Indicate what kind of statement you want to receive and fill in the fields that contain relevant information for the statement to be issued.

Please describe the desired statement *

Name and address manufacturer

Name and address distributor

Name and address importer

Name and address wholesaler

Name and address exporter

Name and address consignee

Name of the Veterinary Medicinal Product

REG NL number of the Veterinary Medicinal Product

Country of origin

Country of destination

Place of destination

Date and place of shipment

Means of transport

Quantity

Label information

Full name of material to be imported/exported

Other relevant information

Applicant
Information about the applicant

Name company *

Address *

Licence number *

Required number of copies of the requested statement *

Additional information
Possible additional remarks, information or questions

Additional information/questions

Do you want to attach documents? *

Yes

Additional file 1

Additional file 2

Additional file 3

Information about the processing of your personal data
We use your data to to process your application. After finalisation of your application we keep these data for analyses, which are intended for internal use. Your data are not shared with others.

Why do we ask you for these data?
We use your data to process your application. To do so we need your permission.

How do we process your data?
We use your data to process your application. As soon as we have completed your application and we have sent you the requested statement, we archive these data.

I have read and understood what happens to my personal data *

Signature

I declare that the information provided in this form is true and that I am aware of the fee for the requested statement *

Salutation *

First name *

Last name *

Telephone number *

E-mail address *

E-mail address invoice (if different)

Place *

Date *

dd/mm/yyyy

* = Input is required

Application form different types of statements

Application form
different types of statements