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Supplier Requalification Form

Supplier Requalification Form

Pursuant to the European GDP Directive and GMP+ Animal Feed, we are obliged to carry out an annual supplier requalification. For this reason, we would like to request that you fill out the digital form below as accurately as possible and upload the relevant attachments.

Company name*:

Address*:

Place*:

Postal Code*:

Country*:

Phone number*:

Website*:

VAT number*:

Contact name 1*:

Phone number 1*:

Email address 1*:

Mobile number 1:

Contact name 2*:

Phone number 2*:

Email address 2*:

Mobile number 2:

Type of organisation*:

Number of Wholesale License:

License expiry date:

Today

Upload Wholesale License:

Number of GDP Certificate:

Expiry date of GDP Certificate:

Today

Upload GDP Certificate:

Number of Controlled Drugs License:

Expiry date of Controlled Drugs License:

Today

Upload Controlled Drugs License:

Number of Manufacturing License:

Expiry date of Manufacturing License:

Today

Upload Manufacturing License:

Number of GMP Certificate:

Expiry date of GMP Certificate:

Today

Upload GMP Certificate:

GMP+ animal feed*:

Yes
No

(if you are GMP+ FSA certified, we will shortly send you an agreement on the storage of retained product samples)

Name of QP/RP*:

Phone number QP/RP*:

Pharmacovigilance email address*:

Form completed by*:

Job title*:

Date/place*:

I agree*:

I declare that I have completed this form truthfully and agree with the Privacy Policy**

Upload other documents:

Enter security code*:

Enter security code:

* Required field
** View our privacy policy

Adresgegevens

Beversestraat 23, 5431 SL Cuijk
Postbus 94, 5430 AB Cuijk
[email protected]
(+31) 0485 33 55 55
(+31) 0485 33 55 66

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