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

Tel Number

Please check th box that applies to you

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)

Upload File

Upload supported file (Max 15MB)

Submitter Name

Job Title

Submitter E-mail

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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