e-form

Notification of Changes to Labelling and Package Leaflets in accordance with article 61(3)

Office use only:
Application received on:





APPLICATION FORM

PLEASE USE THE GUIDELINES FOR FURTHER INFORMATION.

1 PRODUCT DETAILS

1.1 (a) Product Name:





1.1 (b) Active substance/s:





1.1 (c) Pharmaceutical Form:





1.1 (d) Strength/s:





1.1 (e) Marketing Authorisation Number/s:





LI019-05 Appendix 2 Version 01

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