Form for specifying
a dedicated e-mail address for receipt of digital decisions

Please fill in the Form ensuring that all sections are complete.

N.B. Dit formulier is in het Engels opgesteld echter u mag in het Nederlands antwoorden mocht u hier de voorkeur aan geven.

Background
Soon the Dutch Veterinary Medicinal Products Unit will only send decisions digitally. We therefore ask all Marketing Authorisation Holders of veterinary medicinal products (MAH’s) to provide an e-mail address where they will receive the digital decisions of the Dutch Veterinary Medicinal Products Unit. Furthermore all MAH’s must specify the contact person of their organisation.
This form must be completed for each MAH individually. For each MAH, you provide a statement showing that the specified contact person and the dedicated e-mail address are valid.
The statement (an official letter) must contain:
•   Your logo as a MAH
•   Name and address of the contact person and an e-mail address where all decisions about veterinary medicines can be sent
•   A signature of an official who works for the MAH
•   Place and date of signature
The form may therefore not be signed by, for example, a consultant.
If you have any questions or concerns, please contact us via our contact form

General information
General information on the Marketing Authorisation Holder

Salutation

First name *

Last name *

Position *

Company *

Location of establishment

Address *

Telephone number *

E-mail address *

Person authorised for communication on behalf of the Marketing Authorisation Holder (if different from above)

Salutation

First name

Last name

Position

Company

Address

Telephone number

E-mail address

Dedicated e-mail address
Dedicated e-mail address for receipt of digital decisions from the Dutch Veterinary Medicinal Products Unit

Dedicated e-mail address *

Upload statement of validity of the e-mail address and contact person
Please upload a statement showing that the specified contact person and the dedicated e-mail address are valid.

Validity statement *

Additional information
Additional information or additional file upload, if relevant

Other remarks/additional information

Additional file upload

Processing personal data
Permission to use personal data

Information about the processing of your personal data
Your data will be added to your file. We keep your data for as long as you have an authorisation for a veterinary medicinal product. Your data are not shared with others.

Why do we ask you for these data?
We use your data to send you digital decisions. To do so we need your permission.

How do we process your data?
Your data will be added to your file.

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

Signature

I declare that the information provided in this form is true *

Salutation

First name *

Last name *

E-mail address *

Place *

Date of application *

* = Input is required

Form for specifying a dedicated e-mail address for receipt of digital decisions

Form for specifying
a dedicated e-mail address for receipt of digital decisions