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Safety Assessor Association Supporting Membership Form
Please fill out the form below:
I. Company General Information (*)
Company
Name
(required)
Address
Foundation Date
Phone Number
Fax Number
E-mail
(valid email required)
Website
President, Managing Director or Equivalent
Name
Phone Number
Fax Number
E-mail
(valid email required)
If different: Safety Assessor Contact Detail
Name
Phone Number
Fax Number
E-mail
Company Structure/Organization Type
Organizational Form of the Company
Number of Employees
Company Registration Number
Subsidiary of / Independent
II. Membership Type
Number of persons involved in the Safety Assessment activities
Does your company have activities of Safety Assessment for at least 3 years?
Yes
No
How many Safety Assessments do you issue on average per year?
Do you have at least one staff member with a diploma or other evidence of formal
qualifications in pharmacy, toxicology, medicine or a similar discipline,
or a course recognized as equivalent by a Member State?
Yes
No
Have you notified your relevant Competent Authority about your Safety Assessment activities?
Yes
No
Since when is or will your company issue Safety Assessments as per the new
Regulation 1223/2009/EC?
Are you present in any activities, groups, committees at National, European and
International level regarding cosmetics? Which?
III. Other Activities
What other services do you provide? Please indicate all that apply:
Distribution / Marketing
Yes
No
Regulatory Consulting
Yes
No
Advisory Services on GMP EN/ISO 22716
Yes
No
Clinical Studies Services
Yes
No
Responsible Person
Yes
No
Others (please specify)
IV. Other information
How did you learn about ERPA?
What are your reasons for wanting to join ERPA?
What do you wish to achieve through your participation in ERPA?
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