ࡱ; ~a Dbjbj͚ +I\I\$ }}8=|[4==SSi  b[d[d[d[d[d[d[$]_[!X @ !![}}Si[.&.&.&!}RSib[.&!b[.&.&Sl"Wi¹Q"p U*N[[0[6Ua#~aTW" X8aBX  " .&!! [[$ [!!!!a M C:  FORMULARIO PARA SOLICITUDES RELATIVAS AL REGISTRO OFICIAL DE PRODUCTOS Y MATERIAL FITOSANITARIO A1. OBJETO DE LA SOLICITUD: (MARCAR EL QUE CORRESPONDA).1 ( Inclusin de una sustancia activa 12 ( Revisin de clasificacin y etiquetado 2 ( Inclusin Post Annex I (Re-registro) 13 ( Cambio de fabricante 3 (Autorizacin provisional de un preparado 14 ( Cambio de titular de una autorizacin 4 ( Renovacin bajo principios uniformes de preparado 15 ( Aprobacin de una etiqueta comercial 5 ( Autorizacin de un preparado Reglamento 16 ( Ampliacin de envases 6 ( Autorizacin de un coadyuvante o afn 17 ( Autorizacin para realizar ensayos 7 ( Reconocimiento de una autorizacin 18 ( Renovacin de una autorizacin 8 ( Ampliacin de usos autorizados 19 ( Renovacin de sustancia activa 9 ( Revisin por cambio de composicin 20 ( Prrroga provisional de una autorizacin 10 ( Modificacin de condiciones de autorizacin 21 ( Revocacin de una autorizacin 11 ( Certificacin informacin 22 ( Pre-Notificacin segn Reglamento (Otros(especificar) .A2. CIRCUNSTANCIAS PARTICULARES:A3. DESCRIPCION DETALLADA DEL OBJETO DE LA SOLICITUD:ESPACIO RESERVADO PARA REGISTRO DE ENTRADA DE DOCUMENTOSB1. SOLICITANTENombre completo:Calle o plaza y n:Lugar: C.P.: Poblacin: Fax: Provincia: Tno: Pas: e-mail: 1 ( Propietario 2 ( Por licencia 3 ( ConcesionarioB2. REPRESENTANTE DEL SOLICITANTEC1.RECEPCION DE NOTIFICACIONES (MARCAR QUIEN CORRESPONDA)Nombre completo:Calle o plaza y n:1 ( El solicitanteLugar: C.P.: 2 ( El representantePoblacin: Fax: C2. MEDIO PREFERIDOProvincia: Tno: 1 ( Correo ordinario Pas: e-mail: 2 ( Telefax 3 E-mail D1. DENOMINACION DEL PRODUCTOD2. N DE EXPEDIENTE/REGISTRO 1. Nombre comercial en Espaa: 2. Nombre comercial en origen: 3. Otras denominaciones: D3. ESTADO FISICO/TIPO DE PREPARADO: Cdigo UE: D4. COMPOSICION (EN SUSTANCIAS ACTIVAS PURAS), ORIGEN E IDENTIFICACION DE LAS SUSTANCIAS ACTIVASNombre comn (si existe) % p/p gr/100 ml Fabricante Situacin en la UE 1. 2. 3. 4.D5. ENVASES (TIPOS, CAPACIDAD. MATERIAL Y CARACTERSTICAS, N DE HOMOLOGACION) 2. 3. 4. E1. FABRICANTE (PROPIETARIO DE LOS DERECHOS) E2. TITULARIDAD Y UBICACIN DE LAS INSTALACIONESNombre completo: Calle o plaza y n: Lugar: Poblacin: Provincia: Pas: Nombre del Titular: Va: Lugar: Poblacin: Provincia: Pas: 1 ( Instalaciones propias 2 ( Instalaciones ajenas1 ( Planta industrial 2 ( Planta pilotoF1. FUNCION: F3. AMBITO DE UTILIZACION: F2. MODO DE ACCION: F4. USOS SOLICITADOS (CULTIVOS, PLAGAS, DOSIS, TECNICA DE APICACION):1. 2. 3. 4. 5. 6. G1. AUTOLIQUIDACION DE TASAS. Tarifa (Ley 43/2002): Importe: > < EurosG2. PAGO DE TASAS.1 ( Pago en Espaa N del documento 790: 2 ( Pago en el extranjero N del justificante bancario: Fecha de ingreso: Cdigo y nombre de la entidad bancaria: Cdigo y direccin de la sucursal: Nombre de la persona que efecta el ingreso: H DOCUMENTACION QUE ACOMPAAN LA SOLICITUD (Columna izquierda: documentos originales)1( Justificante del ingreso por pago de tasas 9 ( Exenciones de documentacin invocadas 2( Designacin de representacin 10 ( Lista de documentacin aportada (LDA) 3(Certificado de existencia de las instalaciones 11( Propuesta de autorizacin (proyecto de etiqueta) 4(Declaracin de suministro de la sustancia activa 12(Memoria justificativa 5(Declaracin de composicin 13( Documentacin cientfica 6( Licencia de Fabricacin 14( Informacin adicional 7( Carta de acceso de datos protegidos 15( Informes oficiales 8 ( Anexo al formulario para productos presentados segn Reglamento (Otros(especificar) . El solicitante declara bajo su responsabilidad que todos los datos arriba expresados son ciertos y corresponden a los que constan en la documentacin que acompaa a esta solicitud. Lugar y fecha: Cargo que desempea: Firma y sello: Nombre completo: N DNI o pasaporte: SR. 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