MEDDEV2.14.3rev.1FormfortheregistrationofmanufacturersanddevicesInVitroDiagnosticMedic.docVIP

Form for the registration of manufacturers and devices In Vitro Diagnostic Medical Device Directive, Article 10 (Version January 2007) A. Identification of the Competent Authority 6100 Competent Authority code 1) 6110 Competent Authority name 6120 Country code 2) 6140 City 6150 Postal code 6160 Street, number 6165 PO box 6170 Telephone number 6180 Fax number 6190 E-mail B. Identification of the registration 6200 Date of registration 3) 6210 Registration number 4)  6220 Indicate if this is a first registration, a change of information, a discontinuation or a withdrawal of a registration: 5) first change of address discontinuation by manufacturer significant change of product withdrawal by Competent Authority 6230 If change, discontinuation or withdrawal provide previous registration number 6240 Status of the organization making this registration application: 6) Manufacturer Authorized representative I affirm that the information given above is correct to the best of my knowledge. City……………………………………………………… Date……………………………………………………… Name…………………………………………………… Signature…………………………………………….….. City Date Name Signature  C. Identification of the Manufacturer 7) 6250 Manufacturer code 8) 6260 Manufacturer name, long 6265 Manufacturer name, short 6270 Country code 2) 6290 City 6300 Postal code 6310 Street, number 6315 PO box Contact point 6320 Name 6330 Telephone number 6340 Fax number 6350 E-mail D. Identification of the authorized representative9) 6370 Representative code 8) 6380 Representative name 6390 Country code 2) 6392 City 6394 Postal code 6396 Street, number 6398 PO box Contact point 6400 Name 6410 Telephone number 6420 Fax number 6430 E-mail I affirm that the information given above is correct to the best of my knowledge. City………………………………………………………