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Authorisation Holder Representatives Form
Authorisation Holder Representatives Form
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Authorisation holders of medicinal products placed on the market in Malta are required to complete and submit this form.
In order to complete the form, the contact information for the below listed roles need to be supplied.
Local Representative
The authorisation holder’s contact person in Malta (if applicable).
Billing / Finance
The authorisation holder’s contact person for matters regarding invoicing and payment of contributions due to MaMVO by the authorisation holder.
Legal
The authorisation holder’s contact person for legal matters, such as contracts, and changes thereto, between the authorisation holder and MaMVO.
Regulatory Affairs
The authorisation holder’s contact person on matters related to pharmaceutical regulatory affairs, such as national and central marketing authorisations, and the placing on the market of the products that are the subject of such authorisations.
Supply Chain Alert Management
The authorisation holder’s contact person for the investigation of alerts where the pack audit trail concerns events that may have occurred through the pack’s supply chain from the manufacturing site to the local market.
Serialisation Alert Management
The authorisation holder’s contact person for the investigation of alerts, where the root cause of the alert concerns issues with the serialisation of packs and/or the absence/presence of serial numbers in the OBP’s serialisation database.
OBP Product / Pack Data
The authorisation holder’s contact person for the investigation of issues concerning the upload of product and pack data into the MaMVS and/or other markets in the case of intermarket alerts.
Alert Management SPOC (Single Point of Contact) for National Alert Management System (AMS)
The contact details of the authorisation holder’s SPOC for input by MaMVO into the national AMS, NMVS Alerts.
Note:
The same individual may be assigned different roles.
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Next
Organisation Details
Kindly provide the organisation details of the authorisation holder and the name of the contact person for the company / organisation.
* mandatory fields
*Company / Organisation Name
*Contact Person for Company / Organisation
*Address
*City / Town
*Post Code
*Country
--- Select ---
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
*VAT Number
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Next
Local (Malta) Representative
Kindly provide the contact details of the authorisation holder's local representative in Malta and the name of the contact person for the company / organisation (if applicable).
Company / Organisation Name
Contact Person for Company / Organisation
Address
VAT Number
Phone Number
Mobile Phone
Email
Back
Next
Billing / Finance
Kindly provide the details of the authorisation holder’s contact person for matters regarding invoicing and payment of contributions due to MaMVO by the authorisation holder.
* mandatory fields
*Name
*Email
*Phone Number
Also inform Local (Malta) Representative of Issue of Invoice.
Back
Next
Legal
Kindly provide the details of the authorisation holder’s contact person for legal matters, such as contracts, and changes thereto, between the authorisation holder and MaMVO.
* mandatory fields
*Name
*Email
*Phone Number
Back
Next
Regulatory Affairs
Kindly provide the details of the authorisation holder’s contact person on matters related to pharmaceutical regulatory affairs, such as national and central marketing authorisations, and the placing on the market of the products that are the subject of such authorisations.
* mandatory fields
*Name
*Email
*Phone Number
Back
Next
Supply Chain Alert Management
Kindly provide the details of the authorisation holder’s contact person for the investigation of alerts where the pack audit trail concerns events that may have occurred through the pack’s supply chain from the manufacturing site to the local market.
* mandatory fields
*Name
*Email
*Phone Number
Back
Next
Serialisation Alert Management
Kindly provide the details of the authorisation holder’s contact person for the investigation of alerts, where the root cause of the alert concerns issues with the serialisation of packs and/or the absence/presence of serial numbers in the OBP’s serialisation database.
* mandatory fields
*Name
*Email
*Phone Number
Back
Next
OBP Product / Pack Data
Kindly provide the details of the authorisation holder’s contact person for the investigation of issues concerning the upload of product and pack data into the MaMVS and/or other markets in the case of intermarket alerts.
* mandatory fields
*Name
*Email
*Phone Number
Back
Next
SPOC (Single Point of Contact) for National Alert Management System (AMS)
Kindly provide the contact details of the authorisation holder’s SPOC for input by MaMVO into the national AMS, NMVS Alerts.
* mandatory fields
*Name
*Email
*Phone Number
Back
Submit
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