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Control Fee report form - Statens legemiddelverk

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Control Fee report form - Statens legemiddelverk Powered By Docstoc
					CONTROL FEE REPORT FORM                                                                               2011
FOR HOLDERS OF MARKETING AUTHORISATIONS
MEDICINAL PRODUCTS - SALES IN NORWAY
                                                                                                                                        Please send form by e-mail to:
                                                                                                                                          kontrollavgift@legemiddelverket.no

Refer to guidelines on www.legemiddelverket.no                                                                                          Audited form if sent by mail:
                                                                                                                                         Statens legemiddelverk
NOMA will send invoice based on reported figures.                                                                                        Sven Oftedalsv. 8
                                                                                                                                         N-0950 OSLO
                                                                                                                                         TELEFAX: 00 47 22 89 77 99


Name of company
Address:                                                                                                           Telephone:
City                                                                                                            E-mail address:
Country                                                                                                        Contact person:
(Figures in NOK)
Control fee % 2011:                                                                      0.6
                                                     Liable turnover of         Liable turnover of            Control fee                        Control fee
                Please fill in coloured cells.       medicinal products        medicinal products
                          i tabellen                  Total this period       Accumulated this year         Total this period               Accumulated this year
January - March.                  1. Quarter
April - June.                     2.Quarter
July - September.                 3. Quarter
October - December.               4. Quarter


We ask for quarterly reports, even if liable turnover is zero.

We confirm that proceedings are in accordance with the guidelines.

                              Companys signature:                                                                               Date:

Attestation from accountant must be included in the report stating the accumulated control fee no later than two months after termination of accounting year.

Signing accountant confirms that the total fee of:                                                                              NOK
regarding 2011 has been paid in accordance with the control fee guidelines.

We confirm that the company has established a reporting system generating the necessary information to calculate the control fee.
We confirm that the system was controlled and tested:                                          Date of most recent control:

                              Accountant signature                                                                        Date:
                                      Telephone:                                                                E-mail address:

				
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