e-form

Application for a Wholesale Dealer’s Licence for Medicinal Products for Human Use

SECTION A: GENERAL INFORMATION

1 DETAILS OF PROPOSED LICENCE HOLDER

1a If Individual:





Name:





Surname:





ID or passport number:





1b If Company:

Name:





Company registration number:





Legal and judicial representative of company:

Name:





Surname:





ID or passport number:





IN001/10 Appendix 1 Version 1

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