የኢትዮጵ ያ ምግብና ፣ መድኃኒትና የጤና ክብካቤ አስተዳደርና ቁጥጥር ባለሥልጣን

FOOD, MEDICINE AND HEALTH CARE

ADMINISTRATION AND CONTROL AUTHORITY OF ETHIOPIA

Brand Generic Name Strength Dosage BE Manufact Country Agent Reg. Prescreening Evaluation Laboratory Test Total CPO
Name Form urer type Fee (Birr) fee (Birr) fee /batch total /Receipt
(Birr ) batch Number

HCT-SSP HCT 25 mg 25 mg Tablet NA SSP Ethiopia NA - NA NA 1000 1

25 Tablet
Acyclo- Acyclovir 200 200 mg Tablets NA SSP Ethiopia NA - NA NA 1000 2
SSP 200 mg Tablets
Gliben- Glibenclamide 5 mg tablets NA SSP Ethiopia NA - NA NA 1000 1
SSP 5 5 mg Tablets

Total 4000

Pay for Dossier prescreening/Evaluation / Laboratory Test Service

Completed by: Date: Signature: