TYPE OF APPLICATION – HUMAN PRODUCT (Registration/Re-Registration) |
MODULE 1: ADMINISTRATIVE INFORMATION |
SECTION 1: PARTICULARS OF THE PRODUCT |
1.0 Name and address of Applicant |
1.1 |
Type of the Medicinal product licence application |
|
Type of the medicinal product application New/innovator Generic Conditional Authorization Emergency Use Authorization Extension application Duplicate license Renewal/Re-registration* * If variation has been made, information supporting the changes should be submitted. See variation guidelines for registered medicinal products. |
1.2 |
Trade/Proprietary name (proprietary Product name): |
1.3 |
Approved / generic name/Active Pharmaceutical Ingredient: |
1.4 |
Strength of the Active Pharmaceutical Ingredient (API) per unit dosage of the product and specifications of the API: |
1.5 |
Dosage form |
1.5.1 |
Pharmaceutical Dosage form of the product: |
1.5.2 |
Therapeutic Indication (s): |
1.5.2 |
Route(s) of administration (use current list of standard terms - European Pharmacopoeia): |
1.6 |
Packing/Pack size of the product: |
1.6.1 |
Pack size: |
1.6.2 |
Primary packing materials: |
1.6.3 |
Secondary packing materials: |
1.7 |
Visual Description of the product |
1.8 |
Proposed/Approved Shelf life of the product (In months): |
1.9 |
Pharmacotherapeutic group and ATC Code |
1.10 |
Legal category |
1.11 |
Country of origin or country of release: |
1.12 |
Product Marketing Authorisation in the country of origin. (Attach certificate of pharmaceutical product from competent regulatory authority) |
1.12.1 |
Registration status from countries with Stringent Regulatory Authorities where applicable |
1.12.2 |
List of countries in which a similar application has been submitted |
1.12.3 |
Statement on whether an application for the Marketing Authorisation has been previously rejected, withdrawn or repeatedly deferred in the East Africa Community Partner States |
1.12.4 |
Certificates of approval of Drug Master File by Stringent Regulatory Authority |
1.12.5 |
Manufacturing Licence and Product registration certificate/Licence |
1.13 |
Name(s) and complete address (es) of the manufacturer(s) |
1.13.1 |
Name and complete address(es)of the manufacturer(s) of the FPP, including the finished pharmaceutical product release if different from the manufacturer. |
1.13.2 |
Name(s) and complete address (es) of the manufacturer(s) of the active pharmaceutical ingredient |
1.14 |
Compliance to Good Manufacturing Practice and Good Clinical Practice |
1.14.1 |
Good Manufacturing Practice from the Board |
1.14.2 |
Good Clinical Practice or Good Laboratory Practice |
1.15 |
Name and complete address of the Local Technical Representative of Manufacture (for finished pharmaceutical Product) |
1.16 |
Product Information: Summary of Product Characteristics, Prescribers/Patient information leaflet, Mock-ups and Photo scan of the product: |
1.17 |
State the reference/monograph standard used for Finished Medicinal Product. |
1.18.1 |
Specification of active ingredient(s) from active pharmaceutical ingredient manufacturer (Specification number and Version): |
1.18.2 |
Specification of active ingredient(s) from FPP manufacturer (Specification number and Version): |
1.18.3 |
Specification of Finished Pharmaceutical Product (Specification number and Version): |
1.19 |
Name and address (physical and postal) of the Contract Research Organisation(s) where the clinical studies of the product were conducted. (If applicable) |
1.20 |
DECLARATION BY AN APPLICANT That information is true and correct
Name, position and signature ………………………………….
Official stamp:………………………….. * Note: If fees have been paid, attach proof of payment |