Company Name

Name of the responsible person First Name

Last Name

Company Address Street Address

Address Line 2

City

State/Region/Province

Postal / Zip Code (Mention NONE if not applicabel)

country

Postal Code if no applicable mention as 0000

Telephone Enter country code-area code-telephone

Email Email

Purpose of US Agent Appointment

Drug Establishment Registration

ANDA or NDA Filing

DMF filing

Labaler code request

Controlled Correspondence

Other

Select the purpose for US Agent Appointment

Name of Responsible person First Name

Last Name

Official Titile Manager, CEO or whichever is applicable.

Date-Time

Terms and Conditions

I Accept Terms and Conditions