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<h1>Application form</h1> <p><a target="_blank" href="/web/20150407082508/http://www.whocc.no/filearchive/documents/application_form_2011.doc">Print version</a></p> <form action="./" method="post" autocomplete="off"> <input type="hidden" name="action" value="review"/> <p> <input style="float:left" type="checkbox" name="appform[apply_for_ATC]" id="apply_for_ATC" value="ATC"/> <label for="apply_for_ATC">ATC</label><br/> <input style="float:left" type="checkbox" name="appform[apply_for_DDD]" id="apply_for_DDD" value="DDD"/> <label for="apply_for_DDD">DDD (Marketing authorization is needed)</label></p> <h3>Requested by</h3> <table cellspacing="0" cellpadding="0" border="0"> <tr> <td>Name:</td> <td><input type="text" size="40" name="appform[name]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td>Company:  </td> <td><input type="text" size="40" name="appform[company]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td valign="top">Address:</td> <td><textarea name="appform[address]" rows="3" cols="32" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"></textarea></td> </tr> <tr> <td>Country: </td> <td><input type="text" size="40" name="appform[country]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td>Email:</td> <td><input type="text" size="40" name="appform[email]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr><td><br/></td><td></td></tr> <tr valign="top"> <td>Active ingredients (preferably INN names): </td> <td><textarea name="appform[active_ingredients]" rows="3" cols="40" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"></textarea></td> </tr> <tr> <td>INN request number:</td> <td><input type="text" size="40" name="appform[INN_request_number]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td>Brand name:</td> <td><input type="text" size="40" name="appform[brand_name]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td>Dosage form:</td> <td><input type="text" size="20" name="appform[dosage_form]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td>Strengths:</td> <td><input type="text" size="20" name="appform[strengths]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td>Manufacturer:</td> <td><input type="text" size="40" name="appform[manufacturer]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td>Main indication*:</td> <td><input type="text" size="40" name="appform[main_indication]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td>Other indications*:</td> <td><input type="text" size="40" name="appform[other_indications]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> <td>* References should be given and submitted (e.g. from SPC)</td> </tr> <tr> <td>Approved dose recommendations*: </td> <td><input type="text" size="40" name="appform[approved_dose_recommendations]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td>ATC code proposal:  </td> <td><input type="text" size="20" name="appform[atc_code_proposal]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> <tr> <td>DDD proposal:  </td> <td><input type="text" size="20" name="appform[ddd_proposal]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></td> </tr> </table> <h3><br/>Status concerning Marketing Authorization</h3> <p>Marketing Authorization (MA) has been approved in the following countries<sup>1)2)</sup>:<br/> <textarea name="appform[countries_approved]" rows="3" cols="40" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"></textarea><br/> Date of approval:  <input type="text" size="10" name="appform[date_of_approval]" style="width:100px" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/> </p> <p>MA application has been submitted in the following countries<sup>2)</sup>:  <br/> <textarea name="appform[countries_submitted]" rows="3" cols="40" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"></textarea><br/> Date of submission:  <input type="text" size="10" name="appform[date_of_submission]" style="width:100px" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/> </p> <p><input type="checkbox" name="appform[application_status]" value="planned"/> A MA application has not yet been submitted, but is planned <input type="text" size="10" name="appform[date_planned]" value="(date)" style="width:100px" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/>, in the following countries: <input type="text" size="50" name="appform[countries_planned]" class="textinput blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/> </p> <p>1) If the indication(s) in any country differ from those given in the application form, please describe these differences in a separate enclosure.<br/> 2) Please indicate type of application (e.g. National, Centralised Procedure, etc) </p> <p><b> Documentation and references (e.g SPC/Prescribing information), in English only, should be uploaded on the next page. Please note that no paper copies are required when the application is submitted electronically followed by our automatic receipt. Application for ATC/DDD is free of charge. </b></p> <script type="text/javascript"> /* <![CDATA[ */ document.write('<inp'+'ut type="hidden" name="sp'+'amblocker" value="42" />') /* ]]> */ </script> <noscript> <p> Type <b>42</b> into this box:<br/> <input class="pinput_off" type="text" maxlength="4" name="spamblocker" value=""/><br/>  <br/> </p> </noscript> <p><input type="submit" value="Show application" class="button blurred mouseout" onfocus="focusitem(this)" onblur="bluritem(this)" onmouseover="mouseover(this)" onmouseout="mouseout(this)"/></p> </form> <div id="last_updated"> <p><i>Last updated: 2011-01-04</i></p> </div> </div> </div> </div> <div id="left_bottom"> </div> </div> </body> </html>