OTC Drug Product Listing Form

Labeler

Labeler Name

Labeler DUNS Number (Required, if DUNS Number Request Service need, please purchase and fill out the DUNS Number request form.)

Name of Contact Person

Phone Number

Please check the box that applies to you * Required

Own-Label Manufacturer

Private Label Distributor (PLD)

Contract Manufacturer

API Manufacturer

Packer

Labeler

Relabeler

Repacker

Transfiller

Manufacturer Name

Manufacturer DUNS Number

Prioprietary Name (Brand Name)

Intended Use of the Drug

Inner Package

Outer Package

Labeler Code (10 Digits)

Upload File

Upload supported file (Max 15MB)

Upload File

Upload supported file (Max 15MB)

Ingredients List File 1

Upload File

Upload supported file (Max 15MB)

Ingredients List File 2

Upload File

Upload supported file (Max 15MB)

If you have more products, please send the information to ask@provisionfda.com

Submitter Name

Submitter Job Title

Submitter Email

Thanks for submitting!

13925 City Center Dr. Suite 200, Chino Hills, CA 91709 | Phone: +1-909-493-3276 (office) | Email: ask@provisionfda.com

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