e-form

Application Form for the withdrawal of a Marketing Authorisation, an Authorisation in accordance with article 126(a) of Directive 2001/83/EC or a Parallel Import Licence

Application received on:
(Office use only)

A separate application form needs to be completed for each product, but different strengths of the same pharmaceutical form or different vial sizes can be grouped into one form. An electronic copy of the application form and pertaining documentation should be submitted through CESP.

LI018/04 Appendix 1 Version 01

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