(Date)
Dockets Management Staff, Food and Drug Administration, Department of Health and Human Services, 5630 Fishers Lane, rm. 1061, Rockville, MD 20852.
Notice of Participation
Docket No. ____
Under 21 CFR part 12, please enter the participation of:
(Name) _______________________________
(Street address) _______________________________
(City and State) _______________________________
(Telephone number) _______________________________
Service on the above will be accepted by:
(Name) _______________________________
(Street address) _______________________________
(City and State) _______________________________
(Telephone number) _______________________________
The following statements are made as part of this notice of participation:
(Signed)_______________________________
21 C.F.R. §12.45