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French; bilingual French/English authority masthead — reviewed original Office text

Undated reagent homologation application form — FORMULAIRE DE DEMANDE D’HOMOLOGATION DES REACTIFS

Currentness under review. Whether this instrument remains applicable is under review. Consult the later instruments and source context below before relying on it.

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REPUBLIQUE DU CAMEROUN REPUBLIC OF CAMEROON PAIX - TRAVAIL - PATRIE PEACE – WORK - FATHERLAND -------------------- -------------------- MINISTERE DE LA SANTE PUBLIQUE MINISTRY OF PUBLIC HEALTH -------------------- -------------------- SECRETARIAT GENERAL SECRETARIAT GENERAL -------------------- -------------------- DIRECTION DE LA PHARMACIE, DU DEPARTMENT OF PHARMACY, DRUGS MEDICAMENT ET DES LABORATOIRES AND LABORATORIES -------------------- -------------------- FORMULAIRE DE DEMANDE D’HOMOLOGATION DES REACTIFS Type de demande : Octroi □ Renouvellement □ variation □ N° de dépôt de dossier : Date de dépôt : Désignation du produit :---------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- Composition qualitative et quantitative complète du produit et ou du coffret :----------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- Utilisations :----------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- Mode d’emploi:--------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------- Pré-qualification OMS ou norme de fabrication : ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------- Performances du réactif ( seuil de détectabilité, sensibilité et spécificité) : ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- Principe de la technique : ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- http://dpml.cm , http://minsante.cm Tel : (237) 222219281 E-mail : info@dpml.cm 1

Rendered from the linked Office original — page 1; retained table layout and symbols. This is a render, not an official PDF page.
Rendered from the linked Office original — page 1; retained table layout and symbols. This is a render, not an official PDF page.

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Présentation : ---------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- Adresse complète du fabricant :-------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- Adresse du site de fabrication et du conditionnement :--------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- Adresse complète de l’exploitant :----------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Adresse complète du demandeur/Futur titulaire :---------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- Adresse complète du ou des distributeur (s) :----------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------- Nom et adresse du représentant du demandeur au Cameroun : ---------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- Nom et adresse du pharmacien (inscrit à l’ordre) interlocuteur au Cameroun :------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------- La durée de vie du produit (en mois) :------------------------------------------------------------------------------------ Le Prix Grossiste Hors Taxe du pays d’origine (FCFA):---------------------------------------------------------------- Le Prix Public Cameroun (FCFA):------------------------------------------------------------------------------------------- Fait le, à :--------------------------------------------- http://dpml.cm , http://minsante.cm Tel : (237) 222219281 E-mail : info@dpml.cm 2

Rendered from the linked Office original — page 2; retained table layout and symbols. This is a render, not an official PDF page.
Rendered from the linked Office original — page 2; retained table layout and symbols. This is a render, not an official PDF page.

Official source for this passage

Visa : http://dpml.cm , http://minsante.cm Tel : (237) 222219281 E-mail : info@dpml.cm 3

Rendered from the linked Office original — page 3; retained table layout and symbols. This is a render, not an official PDF page.
Rendered from the linked Office original — page 3; retained table layout and symbols. This is a render, not an official PDF page.

Official source for this passage