UNOFFICIAL PREPARATION COPY
PAYMENT IDENTIFICATION NUMBERNOT YET ASSIGNED
1. COMPANY NAME AND ADDRESS
1.1 EMPLOYER IDENTIFICATION NUMBER (EIN)
3. TYPE OF PREMARKET APPLICATION
3.2 ORIGINAL APPLICATION OR SUPPLEMENT TYPE
4. QUALIFIED SMALL BUSINESS?
4.1 SMALL BUSINESS DECISION NUMBER
5. HAVE ALL ESTABLISHMENT REGISTRATION FEES DUE BEEN PAID?
6. APPLICATION FEE EXCEPTION / WAIVER
7. SUPPLEMENT ADDING ADULT USE AFTER A PEDIATRIC FEE EXEMPTION?
INTERNAL PREPARATION CERTIFICATION — NOT PART OF THE FDA FORM
This document is an unofficial preparation copy generated by a local prototype. It does not submit Form FDA 3601, create an FDA invoice, or generate an official MD payment identification number. Submit and verify the final cover sheet in FDA's official MDUFA system. Public reporting burden for the official collection is estimated at 18 minutes per response; OMB No. 0910-0511.