Form C

Name of Company*

Company Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone # of Company*

Contact Fax # of Company*

Authorized applicant (Name of the person)*

First Last

Phone*

Email*

Name of Product*

Date Requested*

Expected product launch date*

Type of the product*

Therapeutic
Cosmetic

Do you need cosmetic notification number?*

Yes
No

Description of the product*

Is it a new product?*

Yes
No

Is it a new licensing application?*

Yes
No

Is it an existing product?*

Yes
No

what is the existing license number (DIN/NPN/OTHER)*

Do you need amendments in existing licensed product?*

Yes
No

What type of amendments you intend to accomplish?*

Do you need certification for your product?*

yes
No

What is the type of certification*

Nature of the product*

Product functions (purpose and proposed product action)*

The product is*

Certification / License requested ( DIN / NPN / OTHER)*

Is Formulation Sheet ready for product?*

Yes
No

Formula Sheet

Max. file size: 1 GB.

Is Formulation need assessment?*

Yes
No

Please note changes in formula or reformulation work if needed for regulatory compliance will cost you extra and notified to you

Label on container and label on box or any inserter

Max. file size: 1 GB.

Application type- Classification*

Name of licensing facility where product is manufactured*

(Name of the company / Company code /Company number / License number)

List of medicinal ingredients / Quantity per dosage unit percent*

List of non-medicinal ingredients/Quantity per dosage unit percent*

Do you intend ti file claims for your product/what are the claims?*

Yes
No

Container type*

Jar
Tube

Qty / unit*

Comments / Do you want to provide any other information about your product?*

Product Licensing, Notification or Certification Form