药监局授权委托书格式

授权委托书

我公司奥林巴斯（北京）销售服务有限公司成都分公司 兹委托 四川欧依洛医疗器械有限公司 在南充市药品监督管理局 医疗器械 处（分局）办理 内窥镜摄像系统、电切镜附件、电外科手术器械、超声内窥镜专用水囊和水囊外鞘管、气腹机第二类医疗器械经营备案凭证的相关事宜。

奥林巴斯（北京）销售服务有限公司成都分公司

2015 年 05 月21日

授权书

兹授权 邓卫兵 身份证号360124199011150354为我公司代表，负责关于办理 内窥镜摄像系统、电切镜附件、电外科手术器械、超声内窥镜专用水囊和水囊外鞘管、气腹机经营许可的相关事宜，请予以接洽。

授权公司：四川欧依洛医疗器械有限公司

法定代表人签字： 被授权人签字：

日 期：2015年05月21日

《授权委托书》填表说明

1、申请单位到市药品监督局办理行政许可事项时，申请人不是法定代表人或负责人时，须由法定代表人或负责人开具《授权委托书》给申请人，列明授权范围和委托期限。

申请人凭《授权委托书》到市药品监督局受理大厅办理相关事宜。 2、“委托人”，填写法定代表人或负责人姓名。 “被委托人”，填写具体办事人员姓名。 “工作单位”、“职务”、“联系电话”，据实填写。

3、“兹委托 ① 在北京市药品监督管理局 ② 处（分局）办理 ③ 事宜。”

①：填写被委托人姓名。

②：根据申办事宜内容填写对应的主管处室名称，如“受理办”、“药品注册处”、“安全监管处”、“医疗器械处”等。

③：填写具体办事内容，如“药品经营许可”。

4、“授权范围”，根据具体授权情况，已授权的在“□”中打“√”，未授权的在“□”中打“×”。

“签收 批件的权利”，在横线上填写需领取的证件、批件或有关材料名称，如“《药品生产许可证》正本、副本”。

5、(委托人单位公章)：“加盖委托人所在单位的公章” 被委托人：“由具体办事人员签字”

6、在办理药品注册事项时，如委托人为二人以上的，须分别列明委托人有关情况，并在对应位置，分别签字、加盖公章。

示 范

Authorization

（Administrative license items）

Consignor：

Work unit： Duty： Phone number： Consignee:

Work unit： Duty： Phone number：

At present consign _______ ______ to transact ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ matters concerned at the ______ ______ department (substation), Beijing Drug Administration (BDA).

Scope of authority:

□1、Be entitled to accept the executive notification pursuant to law.

□2、Be entitled to submit、 correct 、redress、 reinforce application materials on consignor’s behalf.

□3、Be entitled to state and defend in the administrative license censoring on consignor’s behalf.

□4、Be entitled to sign & accept authorized document(s) like ______ _____ ______ ______ ______ ______ ______ ______ _______ ________.

□5 、Any other entitlement(s) _______ _______ _______ _______ _______.

Term of consignation:

Consignee:

(the official seal of consignor’s work unit)

Annotation: mark“√” in the □ before the consigned authority, otherwise, mark “×”.

Authorization

（Administrative license items）

Consignor：Xx Li

Work unit：Co. xx Duty：General manager Phone number： Consignee: Xx Luo

Work unit：Co. xx Duty：Business personnel Phone number：

At present consign _ xx Luo_ to transact altering legal representative of Medical Devices Distribution Enterprise License matters concerned at the Accepting department (substation), Beijing Drug Administration (BDA).

Scope of authority:

□1、Be entitled to accept the executive notification pursuant to law.

□2、Be entitled to submit、 correct 、redress、 reinforce application materials on consignor’s behalf.

□3、Be entitled to state and defend in the administrative license censoring on consignor’s behalf..

□4、Be entitled to sign & accept authorized document(s) like: original and duplicate of Medical Devices Distribution Enterprise License. □5、Any other entitlement(s) . Term of consignation: January 20,2005 - January 22 , 2005

Consignee: Xx Luo

(the official seal of consignor’s work unit) January 20 , 2005 January 20 , 2005 Annotation: mark“√” in the □ before the consigned authority, otherwise, mark “×”.

Instruction to fill in the Authorization

1、If the applicant/transactor isn’t the legal representative or isn’t the principal, he/she must have the Authorization consigned by the legal representative/the principal qualifying the consignee’s authority, to apply administrative licenses matters in Beijing Drug Administration(BDA) The applicant transacts relevant matters in the Accepting Hall of BDA, with the Authorization, if necessary.

2、Fill in the name of the legal representative or the principal in the “consignor” item; Fill in the name of the transactor in the “consignee” item. Fill in the following items by the very fact.

3、At present consign ______①______ to transact ____②_matters concerned at the ③___department( substation), Beijing Drug Administration(BDA).

①: the name of the consignee.

②: concrete matters to be handled, such as “drug supply license”.

③: the corresponding responsible department, such as “Acceptance Department”、“Drug Registration Department”、“Drug Safety and Inspection Department”、“Medical Devices Department”etc. 4、“Scope of authority”, according to exact authorized situation, mark “√” in the “□” before authorized items and mark “×” if unauthorized.

“Be entitled to sign & accept authorized document(s) like ______”, fill in the name of the certificate(s)、authorized document(s) and/or relevant material(s) above the underline, such as“original、duplicate of the Drug Manufacturing Certificate”.

5、(the official seal of consignor’s work unit): “to affix the official seal of

consignor’s work unit”

Consignee:“signed by the personnel who hand affairs practically (contractor)”

6、While handling drug registration items, if the consigners outnumber 2, they must list their individual information respectively and sign and affix their official seals where needed.

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