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Payment Assessment Slip COE
FDA medical device registration slip form for payment assessment
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: CDRRHR’s copy
Cashier’s copy
QWP-CDRRHR/LRD-05 Annex 01
Rev. No. 05 Date Effective: 18 October 2017
QWP-CDRRHR/LRD-05 Annex 01
Rev. No. 05 Date Effective: 18 October 2017
DATE: ____________________
DTN:
Applicant Company: _______________________________________________________
Address/E-mail/Tel No./___________________________________________________________
LTO No. _________________________ Validity: _______________________________
DATE: ____________________
DTN:
Applicant Company: _______________________________________________________
Address/E-mail/Tel No.___________________________________________________________
LTO No. _________________________ Validity: _______________________________
PRODUCT INFORMATION
Product Name
: _______________________________________________________
Brand Name
: _______________________________________________________
Sizes
: _______________________________________________________
_______________________________________________________
_______________________________________________________
Packaging
: _______________________________________________________
Registration Number
: _______________________________________________________
Manufacturer
: _______________________________________________________
Packer
: _______________________________________________________
Repacker
: _______________________________________________________
Trader
: _______________________________________________________
Importer
: _______________________________________________________
Exporter
: _______________________________________________________
Distributor
: _______________________________________________________
Suggested Retailer Price
: ___________________________
Number of Samples
: ___________________________
PRODUCT INFORMATION
Product Name
: _______________________________________________________
Brand Name
: _______________________________________________________
Sizes
: _______________________________________________________
_______________________________________________________
_______________________________________________________
Packaging
: _______________________________________________________
Registration Number
: _______________________________________________________
Manufacturer
: _______________________________________________________
Packer
: _______________________________________________________
Repacker
: _______________________________________________________
Trader
: _______________________________________________________
Importer
: _______________________________________________________
Exporter
: _______________________________________________________
Distributor
: _______________________________________________________
Suggested Retailer Price
: ___________________________
Number of Samples
: ___________________________
APPLICATION DETAILS
Certifications (EXEMPTION) 500/product
Others, pls. specify
_______________________________________
APPLICATION DETAILS
Certifications (EXEMPTION) 500/product
Others, pls. specify
_______________________________________
PAYMENT DETAILS
EVALUATOR
Fee
: ________________________
Legal Research Fee (1%):_______________
Surcharge : ________________________
TOTAL
: ________________________
Evaluated by : ________________________
PAYMENT DETAILS
EVALUATOR
Fee
: ________________________
Legal Research Fee (1%):_______________
Surcharge : ________________________
TOTAL
: ________________________
Evaluated by : ________________________
CASHIER
Amount
: ___________________________
OR Number : ___________________________
Date Issued : ___________________________
Received by : ___________________________
RECEIPT DETAILS
Name
Signature
OR Number : ___________________________
Date Issued : ___________________________
Received by : ___________________________
RECEIPT DETAILS
Name
Signature
CASHIER
Amount
: ___________________________
: ________________________________________
: ________________________________________
: ________________________________________
: ________________________________________
