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Payment Assessment Slip CPR
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-02 Annex 01
Rev. 05 Date Effective: 18 October 2017
QWP-CDRRHR/LRD-02 Annex 01
Rev. 05 Date Effective: 18 October 2017
DATE: ____________________
DTN:
Applicant Company: _______________________________________________________
Address/Email/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
: ___________________________
DATE: ____________________
DTN:_______________
Applicant Company: _______________________________________________________
Address/Email/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
: ___________________________
APPLICATION DETAILS
Initial
Renewal
Renewal with Surcharge
Re-application (OLD RSN: ___________)
No. of CPR Validity Applied for (year/s)
OTHER REQUESTS
Amendment of CPR
Brand Name clearance
Re-issuance/Reconstruction of CPR
APPLICATION DETAILS
Initial
Renewal
Renewal with Surcharge
Re-application (OLD RSN: ___________)
No. of CPR Validity Applied for (year/s)
OTHER REQUESTS
Amendment of CPR
Brand Name clearance
Re-issuance/Reconstruction of CPR
PAYMENT DETAILS
EVALUATOR
Fee
: ________________________
Legal Research Fee (1%):_______________
Surcharge : ________________________
TOTAL
: ________________________
Evaluated by : ________________________
________________
Provisional Permit to Carry
Export Certificate
Others, pls. specify
_______________________________________
CASHIER
Amount
: ___________________________
OR Number : ___________________________
Date Issued : ___________________________
Received by : ___________________________
RECEIPT DETAILS
Name
: ________________________________________
Signature
: ________________________________________
PAYMENT DETAILS
EVALUATOR
Fee
: ________________________
Legal Research Fee (1%):_______________
Surcharge : ________________________
TOTAL
: ________________________
Evaluated by : ________________________
________________
Provisional Permit to Carry
Export Certificate
Others, pls. specify
_______________________________________
CASHIER
Amount
: ___________________________
OR Number : ___________________________
Date Issued : ___________________________
Received by : ___________________________
RECEIPT DETAILS
Name
: ________________________________________
Signature
: ________________________________________
