EUROPEAN AUTHORIZED REPRESENTATIVE

1. MANUFACTURER INFORMATION
Legal Manufacturer / OEM / OBL Name*
Street*
City /Pincode*
Country*
Website Address
2. SERVICE REQUEST
SERVICE INTRESTED	Select European Authorized Representative (EAR) EAR + EU Registration Technical File Review, EAR and EU Registration EAR + EU Registration +DOC Support Technical Documentation, NB Coordination + EAR +SRN EAR+EU Registration+ Free Sale Certificate
NUMBER OF MEDICAL DEVICES	Select 1 2 3 4 5 More devices?, Attach word/excel sheet
3. MEDICAL DEVICE INFORMATION
[01] Name of the Medical Device*
GMDN Code*
Device Class*	Select Class 1 Class 1s Class 1m Class 1r Class 11 Class 111 Class A Class B Class C Class D Don't Know
Declaration of confirmity (Upload)
[02] Name of the Medical Device
GMDN Code
Device Class	Select Class 1 Class 1s Class 1m Class 1r Class 11 Class 111 Class A Class B Class C Class D Don't Know
Declaration of confirmity (Upload)
[03] Name of the Medical Device
GMDN Code
Device Class	Select Class 1 Class 1s Class 1m Class 1r Class 11 Class 111 Class A Class B Class C Class D Don't Know
Declaration of confirmity (Upload)
[04] Name of the Medical Device
GMDN Code
Device Class	Select Class 1 Class 1s Class 1m Class 1r Class 11 Class 111 Class A Class B Class C Class D Don't Know
Declaration of confirmity (Upload)
[05] Name of the Medical Device
GMDN Code
Device Class	Select Class 1 Class 1s Class 1m Class 1r Class 11 Class 111 Class A Class B Class C Class D Don't Know
Declaration of confirmity (Upload)
4. SUBMITTER INFORMATION
Contact Person* Select Mr Mrs Dr Prof Ms
Job Title*
Contact Number*
Contact Email*