Compulsory Optional (other signature) date Place, date Signature Signature ......................................................... ………………………………………….. Person responsible Other person Surname Surname First name First name Job title Job title Telephone E-mail The application must be sent to For inquiries contact Swissmedic, Swiss Agency for Therapeutic Products Telephone +41 58 462 02 11 P.O. Box, Hallerstrasse 7, 3000 Berne 9 Fax +41 58 462 02 12
Compulsory Optional (other signature) date Signature ………………………………………….. Person responsible Surname First name Job title Telephone E-mail Place, date Signature ......................................................... Other person Surname First name Job title The application must be sent to Swissmedic, Swiss Agency for Therapeutic Products P.O. Box, Hallerstrasse 7, 3000 Berne 9 For inquiries contact Telephone +41 58 462 02 11 Fax +41 58 462 02 12
zl000_00_003e_foapplicationforauthorisationvariationhumanmedicin.docx