Industry - Download as DOC by c17gf7Uo

VIEWS: 7 PAGES: 2

									               Pharmacovigilance Training Program
            Jordan Food & Drug Administration (JFDA)
                         June 30, 2012

Registration Form:

First Name :
Middle Name :
Last/Family Name :
Contact information
Title :                                   Institution :
Department:                               Telephone :
Fax :                                     Email address(s) :
Address :                                 Mobile :
Institution information
Name :                                    Type (choose one of the following) :
                                            - Industry
                                            - Drug Agent
                                            - CRO
                                            - University
                                            - Hospital
                                            - Academic
                                            - Other (Specify):
Logistics
Do you need a formal invitation letter for visa or administrative purposes?
(yes/No)


                                      1
Payment details/ FEES:
     My company is a will pay the JFDA fee of JD 100
Date: .................................................................................................................
Signature: .........................................................................................................


Registration form to be sent back by fax to:
      JFDA at      Fax:        5105916
                   Email:      Nevin.al-haj@jfda.jo
                               Faisal.Barahmeh@jfda.jo
If you need any information please contact:
    - Nevin Al-haj@jfda.jo:
            Tel: ++ 962 6 5632000 Ext. 2231
            Mobile: 0797895854
    - Faisal Barahmeh:
            Tel: ++ 962 6 5632000 Ext. 2422
            Mobile: 0799054466




                                                           2

								
To top