Application form

Import declaration veterinary medicinal product from outside the EEA
based on use of medicinal products outside the terms of the marketing authorisation (article 112 to 114 VMR)

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

Please fill in all relevant information.
Dit formulier is in het Engels. U mag in het Nederlands antwoorden mocht u hier de voorkeur voor hebben.

Type of statement
Information on the requested type of statement
Please note the veterinary medicinal product must be authorised in a third country for the same animal species and same indication as for which you are using it.

Type of statement *

Information on the animal(s) to be treated

Target species *

Number of animals treated *

Diagnosis of the animal(s) *

Information on the company where the animals are treated

Name and address company *

UBN number company *

Information on the veterinary medicinal product to be imported from a third country

Name of the Veterinary Medicinal Product *

Authorisation number of the Veterinary Medicinal Product *

Country of origin *

Name and address marketing authorisation holder *

Active substance(s) *

Withdrawal period *

Package size *

Total number of imported products *

Other relevant information

Applicant
Information about the applicant

Information on the wholesaler

Does a wholesaler import the VMP on behalf of the veterinarian?

Name and address wholesaler

Contact person wholesaler

Salutation *

First name *

Last name *

Telephone number *

E-mail address *

Information on the responsible veterinarian

Name veterinarian *

Salutation *

First name *

Last name *

Telephone number *

E-mail address *

Address *

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 Import declaration veterinary medicinal product from outside the EEA based on use of medicinal products outside the terms of the marketing authorisation (article 112 to 114 VMR)

Application form

Import declaration veterinary medicinal product from outside the EEA
based on use of medicinal products outside the terms of the marketing authorisation (article 112 to 114 VMR)