Bar Code[1]                                                       原始編號(hào)
                                                                Original Application No. [2]
                                                                 受理號(hào)
                                                                Handling No. [3]
國(guó)家食品藥品監(jiān)督管理局
STATE FOOD AND DRUG ADMINISTRATION
藥品注冊(cè)申請(qǐng)－境外申請(qǐng)人用表
DRUG REGISTRATION APPLICATION -- FOR FOREIGN APPLICANTS
                                                                             
聲明
STATEMENT
我們保證：
We guarantee:
 (1) 本申請(qǐng)遵守《中華人民共和國(guó)藥品管理法》、《中華人民共和國(guó)藥品管理法實(shí)施條例》和《藥品注冊(cè)管理辦法》等法律、法規(guī)和規(guī)章的規(guī)定；
This application complies with laws and regulations such as Drug Administration Law of The People’s Republic of China, Implementing Regulation of the Drug Administration Law of The People’s Republic of China, and Drug Registration Regulation;
 (2) 申請(qǐng)表內(nèi)容及所提交資料、樣品均真實(shí)、來(lái)源合法，未侵犯他人的利益，其中試驗(yàn)研究的方法和數(shù)據(jù)均為本藥品所采用的方法和由本藥品得到的試驗(yàn)數(shù)據(jù)；
The content of this application form, the submitted dossier and the samples are true and legal, without infringing any other’s rights. All the test methods and data are obtained from the drug we’re applying for;
 (3) 一并提交的電子文件與打印文件內(nèi)容完全一致。
The accompanied electronic version is in perfect accordance with the printed version.
如查有不實(shí)之處，我們承擔(dān)由此導(dǎo)致的一切法律后果。
We will take all the legal consequences of any false statements.
其他特別申明事項(xiàng)：對(duì)附加申請(qǐng)事項(xiàng)的說(shuō)明：我公司代理申請(qǐng)進(jìn)口的×××公司的××為已有國(guó)家藥品標(biāo)準(zhǔn)的品種，用于生產(chǎn)××制劑。根據(jù)《藥品注冊(cè)管理辦法》中“進(jìn)口化學(xué)藥品申報(bào)資料和要求”，申請(qǐng)已有國(guó)家藥品標(biāo)準(zhǔn)的原料藥不需進(jìn)行臨床試驗(yàn)，故申請(qǐng)免做臨床試驗(yàn)。
Other statements: Explanation for the supplemental application: We act as the agency of *** company for the import registration of **, a drug substance with available National Drug Standards in China which is used to produce ** preparations. According to the requirements on imported chemical drugs by Drug Registration Regulation, no clinical trial is needed for the application of drug substances with available National Drug Standards in China. Therefore we apply for omitting the clinical trials.
  
申請(qǐng)事項(xiàng)
APPLICATION ITEMS
1 本申請(qǐng)屬于：進(jìn)口注冊(cè)
This application is for: import registration
2 申報(bào)事項(xiàng)：臨床試驗(yàn)
Application for: clinical trial
3 藥品注冊(cè)分類(lèi)：化學(xué)藥品
Registration category: chemical drugs
4 附加申請(qǐng)事項(xiàng)：減或者免臨床研究
Supplemental application for: Waiver or less subject numbers for clinical trial
  
藥品情況
DRUG INFORMATION
5 藥品通用名稱(chēng)：**
Generic name of the drug: **
6 通用名稱(chēng)來(lái)源：藥典委員會(huì)
Source of the generic name: Chinese Pharmacopoeia Commission
7 英文名稱(chēng)/拉丁名稱(chēng)：**
English name/Latin name: **
8 漢語(yǔ)拼音：**
Chinese Phonetic Alphabet: **
9 化學(xué)名稱(chēng)：**
   Chemical name: **
10其他名稱(chēng)：
Other Names: 
11商品名：無(wú)
Drug Trade Name: none
12制劑類(lèi)型：非制劑 原料藥
Product category: API
13規(guī)格：
Strength:
14同品種已被受理或同期申報(bào)的其他制劑及規(guī)格：
  Other dosage forms and strengths of the same drug handled by or submitted to SFDA by the same applicant:
15包裝：直接接觸藥品的藥包材：
Packing: immediate package material:
包裝規(guī)格：
Packing size:
16藥品有效期：**個(gè)月
  Shelf life: ** months
17處方（含處方量）：
  Formulation (including quantitative composition):
   活性成分/中藥藥味/…：
  Active ingredients/ Chinese medicinal materials /…:
18原/輔料來(lái)源：
Source of raw materials and excipients:
19中藥材標(biāo)準(zhǔn)：
Specifications of Chinese medicinal materials:
20藥品標(biāo)準(zhǔn)：藥品標(biāo)準(zhǔn)：自擬標(biāo)準(zhǔn)
  Specifications: specifications: in-house specifications
   來(lái)源：其它標(biāo)準(zhǔn)：企業(yè)標(biāo)準(zhǔn)
  Source of specifications: other specifications: in-house specifications
21適應(yīng)癥或功能主治：
  Indications or functions:
   適應(yīng)癥分類(lèi)：
  Indication category:
   適應(yīng)癥：
  Indication:
  
相關(guān)情況
RELATIVE INFORMATION
22專(zhuān)利情況：專(zhuān)利權(quán)屬聲明：我們聲明：本申請(qǐng)對(duì)他人專(zhuān)利不構(gòu)成侵權(quán)。
  Patent information: patent declaration: we declare that this application does not infringe any other’s patent.
23是否涉及特殊管理藥品或成分：
Whether the drug is subject to special administration or contains any ingredients subject to special administration：
 否
No
立項(xiàng)批復(fù)文件號(hào)[4]：
The number of the official approval document of the proposal:
24中藥品種保護(hù)[5]：
Drugs under application for TCM protection:
25同品種新藥監(jiān)測(cè)期[6]：
  Monitoring period of new drugs of the same drug by other enterprises:
   無(wú)
  None
26本次申請(qǐng)為：首次申請(qǐng)
  This application is: initial application
  
申請(qǐng)人及委托研究機(jī)構(gòu)
APPLICANTS AND CONTRACT RESEARCH ORGANIZATIONS
27機(jī)構(gòu)1（境外制藥廠商）：
  The 1st organization (foreign manufacturer):
   中文名稱(chēng)：**
   Chinese name: **
   英文名稱(chēng)：**
   English name: **
   法定代表人：** 職位：**
   Legal representative: ** Position: **
   注冊(cè)地址：**
   Registered address: **
   國(guó)家或地區(qū)：**
   Country or region: **
   注冊(cè)申請(qǐng)負(fù)責(zé)人：**    職位：**
   The person responsible for registration: **    Position: **
   電話：**   傳真：**
   Tel: **      Fax: **
   電子信箱：**
   E-mail: **
   法定代表人（簽名）：          （加蓋公章處）
  Legal representative (signature):    (affix with the official seal)
                                 年    月     日
                                Year  month  date
28機(jī)構(gòu)2（進(jìn)口藥品生產(chǎn)廠）：
  The 2nd organization (manufacturer of the imported drug):
   中文名稱(chēng)：**
   Chinese name: **
   英文名稱(chēng)：**
   English name: **
   法定代表人：** 職位：**
   Legal representative: ** Position: **
   生產(chǎn)地址：**
   Manufacturing address: **
國(guó)家或地區(qū)：**
   Country or region: **
注冊(cè)申請(qǐng)負(fù)責(zé)人：**    職位：**
   The person responsible for registration: **    Position: **
   電話：**   傳真：**
   Tel: **      Fax: **
   電子信箱：**
   E-mail: **
   法定代表人（簽名）：          （加蓋公章處）
  Legal representative (signature):    (affix with the official stamp)
                                 年    月     日
                                Year  month  date
29機(jī)構(gòu)3（進(jìn)口藥品國(guó)外包裝廠）：
  The 3rd organization (foreign packers of the imported drug):
   無(wú)
  None
30機(jī)構(gòu)4（進(jìn)口藥品注冊(cè)代理機(jī)構(gòu)）：
  The 4th organization (import registration agent):
   本機(jī)構(gòu)負(fù)責(zé)繳費(fèi)
  The organization pays for the registration fee.
   中文名稱(chēng)：**
   Chinese name: **
   英文名稱(chēng)：**
   English name: **
   組織機(jī)構(gòu)代碼[7]：**
   Organization Code: **
   法定代表人：**  職位：**
   Legal representative: **  Position: **
   注冊(cè)地址：**  郵編：**
   Registered address: ** Zip code: **
   通訊地址：**  郵編：**
   Mailing address: **  Zip code: **
   注冊(cè)申請(qǐng)負(fù)責(zé)人：**  職位：**
   The person responsible for registration: **  Position: **
   聯(lián)系人：**  職位：**
   Contact person: **  Position: **
   電話：** 傳真：**
   Tel: **    Fax: **
   電子信箱：**  手機(jī)：**
   E-mail: **      Cell phone: **
   法定代表人（簽名）：          （加蓋公章處）
  Legal representative (signature):    (affix with the official stamp)
                                 年    月     日
                                Year  month  date
31委托研究機(jī)構(gòu)：
  Contract research organization:
32申報(bào)資料：[8]
  Application dossier:
   4號(hào)資料：4號(hào)資料_barcode.doc
   Dossier No. 4: dossier No. 4_ barcode.doc
   7號(hào)資料：7號(hào)資料_ barcode.doc
   Dossier No. 7: dossier No. 7_ barcode.doc
 8號(hào)資料：8號(hào)資料_ barcode.doc
   Dossier No. 8: dossier No. 8_ barcode 3.doc
 16號(hào)資料：16號(hào)資料_ barcode.doc
   Dossier No. 16: dossier No. 16_ barcode.doc
 28號(hào)資料：28號(hào)資料_ barcode.doc
   Dossier No. 28: dossier No. 28_ barcode.doc
  
經(jīng)審查，本表填寫(xiě)符合形式審查要求。                                           審查機(jī)關(guān)
After examination, the format of this application form is considered to be in accordance with the requirements.                                                    The examining authority
審查機(jī)關(guān)：             審查人簽名：              日期：  年   月     日
The examining authority:   the signature of the examiner:  date:    year  month  date
本表必須使用SFDA制發(fā)的申請(qǐng)表填報(bào)軟件填寫(xiě)、修改和打印。不得涂改。數(shù)據(jù)核對(duì)碼：**********
The application form must be filled in, amended or printed with the software provided by SFDA and shall not be altered. The bar code is **********.
  
 [1]: The bar code is created randomly by the software. Each time the application form is amended, a new bar code will be created.
 [2], [3]: To be given by SFDA after the application is handled.
 [4]: If the drug is subject to special administration or contains any ingredients subject to special administration, the applicant should propose and get the official approval document of the proposal from SFDA before filling in this application form.
 [5]: For those products under application for TCM protection, application for generic products of the same drug will be suspended from the date the protection application was accepted to the date an administration decision is made.
 [6]: To ensure public health, SFDA may implement a monitoring period for the approved new drugs to monitor the safety. For new drugs under the monitoring period, SFDA shall not approve production, dosage change and importation of the drug by other enterprises.
 [7]: In China, every organization is identified exclusively by an organization code. It’s not applicable for foreign organizations.
 [8]: The application dossier is prepared and submitted by the registration agent accompanied with the application form.