e-form

Application for a Pharmacy 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 No.:





PHY004/01 Appendix 1A Version 1

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