APPLICANT INFORMATION Applicant’s Legal Business Name Doing Business As (DBA) Name If applicable Date – Applicant’s Physical Address of Any other businesses Contact Person for VDIP Accreditation Facility handling OTC Medical Devices at this facility? Name Telephone Number Email Address Yes No Type of Application Does your facility take possession of the OTC Is the facility’s OTC Medical Device storage area air Medical Devices that you own? conditioned? New Applicant Reaccreditation Other Yes No Yes No N/A Type of Facility: (Check All That Apply) WD - Wholesale Distributor 3PL - Third Party Logistics RD - Reverse Distributor (non-saleable return products only) *If handling saleable return products, contact Provider NABP MFR - Manufacturer 503B - Outsourcing Facility SD - Sample Distributor RPKG - Repackager VD - Virtual Distributor AD API Distributor DD Rx Device Distributor VET - Veterinary Prescription OTC Medical Devices (Describe) – – GENERAL COMMENTS Reviewer Comments: Applicant Comments: INSTRUCTIONS
APPLICANT INFORMATION Applicant’s Legal Business Name Doing Business As (DBA) Name – If applicable Date Applicant’s Physical Address of Facility Any other businesses handling OTC Medical Devices at this facility? Contact Person for VDIP Accreditation Yes No Name Telephone Number Email Address Type of Application Does your facility take possession of the OTC Medical Devices that you own? Is the facility’s OTC Medical Device storage area air conditioned? New Applicant Reaccreditation Other Yes No Yes No N/A Type of Facility: (Check All That Apply) WD - Wholesale Distributor 3PL - Third Party Logistics Provider RD - Reverse Distributor (non-saleable return products only) *If handling saleable return products, contact NABP MFR - Manufacturer 503B - Outsourcing Facility SD - Sample Distributor RPKG - Repackager VD - Virtual Distributor AD – API Distributor DD – Rx Device Distributor VET - Veterinary Prescription OTC Medical Devices (Describe) GENERAL COMMENTS Reviewer Comments: Applicant Comments: INSTRUCTIONS