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ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
填报说明
1、本表由申请核发《药品经营许可证》的申请人用原件填写,报药店所在地县(市)药品监督管理局和市区的市药品监督管理局各一份(市区的市药品监督管理局同意筹建的只须一份)。
2、隶属单位,指企业直接隶属的部门或单位,无隶属单位的,应注明“(无)”。
3、企业法人单位填写法定代表人,册除“企业负责人”字样;非企业法人单位填写企业负责人,册除“法定代表人”字样。
4、向市区的市级药品监督管理局报送本表时,必须提交下列材料:
(1)核发《许可证》书面申请及对照有关规定的自查报告;
(2)所地地药品监督管理局同意筹建通知的原件或复印件;
(3)企业全体人员情况表,并附相关人员的健康证明原件(查验后退回)、复印件;药学从业人员应同时附上相应的资质证明原件(查验后退回)、复印件;
(4)药品经营质量管理制度;
(5)药品监督管理部门要求提供的其它材料或证明。
5、本表所列各项内容填写不下时可另附页。
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
表一
拟开办企业基本情况
企业名称
经济情况
地址
邮编
隶属单位
电话
申办人
联系人
电话
法定代表人
企业代表人
职称
(资格)
从药
年限
电话
质量负责人
职称
(资格)
从药
年限
电话
经营范围
药品
非药品
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
从业人员
总数
药学技术人员总数
执业
药师
从业
药师
副主任
药师以上
主管
药师
药师
药士
药学中专
以上学历
投资情况
注册
资金
万元
固定资产
万元
流动资金
万元
设
施
设
备
营业场所
仓库面积(㎡)
其它验收、养护设备
面积(㎡)
温湿度
调控设备
总面积
常温库
阴凉库
冷库
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
仓库详细地址
表二
企业自查评定
项目缺陷内容
严
重
缺
陷
一
般
缺
陷
自查情况、结论及其他需要说明的问题:
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
申请人(签章):
年月日
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities
ofruraldrinkingwatersources,protectionofdrinkingwatersourcesinruralareasbytheendofthedelimitationofthescopeofprotection,completewithwarningsigns,isolatingnetworkprotectionfacilities