In Vitro Diagnostic Self-Declaration Form
Please complete this form to declare the intended use of your in vitro diagnostic product. All fields are required for operational purposes only.
Organization Name
*
Responsible Person Name
*
First Name
Last Name
Job Title
*
Business Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Product Name or Identifier
*
Product Category
*
Please Select
Clinical Chemistry
Immunoassay
Molecular Diagnostics
Microbiology
Hematology
Other
Intended Use Statement
*
Declaration Statement
*
Date of Declaration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature (Type Full Name)
*
Submit Declaration
Should be Empty: