US FDA Medical Facility Registration
Establishment
*
Establishment Name
*
Street Address
*
City
*
State
*
Country
*
Postal Code
FDA Registration Number
DUNS Number
I hereby authorize MedDeviceCorp to obtain DUNS Number on our behalf
Establishment Contact
*
Name of Contact Person
*
Job Title
*
Mailing Address
*
City
*
State
*
Country
*
Postal Code
*
Tel Number
*
E-Mail
Other business Names
Type of Operation
Manufacturer
Contract Manufacturer
Contract Sterilizer
Specification Developer
Initial Importer
Foreign Exporter
Relabeler
Other (Explain)
US Importer / Distributor
US Importer Name
FDA Registration Number
DUNS Number
Address
E-mail
Tel Number
Medical Device - 1
*
Proprietary Name
*
Common Name
Device Class
Device Code
510 (K) Number
Medical Device - 2
Proprietary Name
Common Name
Device Class
Device Code
510 (K) Number
Medical Device - 3
Proprietary Name
Common Name
Device Class
Device Code
510 (K) Number
Medical Device - 4
Proprietary Name
Common Name
Device Class
Device Code
510 (K) Number
Medical Device - 5
Proprietary Name
Common Name
Device Class
Device Code
510 (K) Number
Medical Device - 6
Proprietary Name
Common Name
Device Class
Device Code
510 (K) Number
I agree to the above Terms and Conditions
Submitter Name
Job Title
Submitter E-mail
