The FDA Registration form - Submitter Information

	PARTY
	PARTY

	All prior notice information must be submitted in the English language except an individual's name, the name of a company, and the name of a street may be submitted in a foreign language.

		SUBMITTER
	FDA Registration No. (If required)
●	Name of Contact Person:
	Company Name: (If applicable)
●	Facility Address: Line 1
	Facility Address: Line 2
●	City:
	State:
	Postal Code:
	Province/Territory:
●	Country:
●	Phone No.:
●	Fax No.:
●	e-Mail address:
		CREDIT CARD
●	Credit Card Type:	American Express MasterCard Visa
●	Credit Card Number.:
●	Expiration Date:	-
●	Name printed on the card:
		AUTHORIZATION
	The undersigned hereby certify that all of the above information are correct. It is also understood, that any request for Prior Notice thru the Lalandia Website will be charged with US$ 15.00 per FDA Confirmation Number, as issued by the FDA in accordance with the Bioterrorism Act of 2002, as amended. Lalandia is hereby authorized to charge on a monthly basis for usage of the Lalandia Website Prior Notice filing to the above mentioned credit card.
●	Please sign with the email address
●	of the Submitter mentioned above: