Medicines and Healthcare Regulatory Products Authority
 
DCP request form

Name of active substance(s)*

*

ATC Code*

*
Product details

Please complete the details for your product

legal basis of application:



Is this a duplicate of an ongoing or finalised procedure?*


Please indicate the procedure number of the original dossier


If you plan to submit any parallel duplicate applications for any of the above mentioned products please indicate
For applications under Article 10(1), 10(3), and 10(4)

Details of the Reference Medicinal Product which must have been authorised for more than 8/10 years in the EEA

Product name, strength and pharmaceutical form

Marketing Authorisation Holder

First Authorisation Date DD/MM/YY



Is the Reference Medicinal Product authorised in the UK?
Other details

By providing the following details, you declare that no other Member State has agreed to act as Reference Member State for a Decentralised Procedure for the above mentioned product

Applicant's preferred submission date MM/YYYY

Please indicate if you have a PL number already allocated for this submission.*
*

PL Number (If yes)

5 digit company number (If no)

Marketing Authorisation Holder*

*

Authorised Contact Person*

*

Marketing Authorisation Holder Address*

*

Email address*

* *

Telephone*

*