<p class="MsoNormal" align="center" style="text-align:center;"> <b>食品药品在线申请</b><b><span>登记表</span></b><b></b> </p> <p class="MsoNormal" align="center" style="margin-left:-7.0500pt;text-indent:5.2500pt;text-align:center;"> <span>咨询日期：</span> <span>年</span><span> </span><span>月</span><span> </span><span>日</span><b> </b>食药申<span>字</span>[ ]<span>第</span><span> </span><span>号</span> </p> <table class="MsoNormalTable" align="center" style="width:677.25pt;"> <tbody> <tr> <td width="903" valign="center" colspan="6" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal" align="center" style="margin-left:21.1000pt;text-indent:-21.1000pt;text-align:center;"> <b><span style="font-family:宋体;font-size:14pt;">申请人基本情况</span></b><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> </tr> <tr> <td width="75" valign="center" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal" align="center" style="text-align:center;"> <span style="font-family:宋体;font-size:12.0000pt;">姓名</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> <td width="122" valign="center" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal" align="center" style="text-align:center;"> <span style="font-family:宋体;font-size:12.0000pt;"> </span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> <td width="106" valign="center" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal" align="center" style="text-align:center;"> <span style="font-family:宋体;font-size:12.0000pt;">性别</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> <td width="145" valign="center" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal" align="center" style="text-align:center;"> <span style="font-family:宋体;font-size:12.0000pt;"> </span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> <td width="94" valign="center" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;">联系电话 </span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> <td width="359" valign="center" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal" align="center" style="text-align:center;"> <span style="font-family:宋体;font-size:12.0000pt;"> </span> </p> </td> </tr> <tr> <td width="197" valign="center" colspan="2" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;"> 身份证号</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> <td width="251" valign="center" colspan="2" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;"> </span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> <td width="94" valign="center" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;">电子信箱</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> <td width="359" valign="center" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;"> </span> </p> </td> </tr> <tr> <td width="197" valign="center" colspan="2" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;"> 住所地</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;">（经常居住地）</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> <td width="705" valign="center" colspan="4" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;"> </span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> </tr> <tr> <td width="197" valign="center" colspan="2" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <b><span style="font-family:宋体;font-size:14pt;">申请方式</span></b><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> <td width="705" valign="center" colspan="4" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;">A来访 B电话 C信函 D网络 </span><b><span style="font-family:宋体;font-size:12pt;">您的选择：</span></b><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> </tr> <tr> <td width="903" valign="center" colspan="6" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <b><span style="font-family:宋体;font-size:14pt;">申请事项类别</span></b><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> </tr> <tr> <td width="903" valign="center" colspan="6" style="border:1.0000pt solid windowtext;"> <p class="15" style="margin-left:24pt;text-indent:-24pt;"> <span style="font-family:宋体;font-size:12.0000pt;">一、 </span><span style="font-family:宋体;font-size:12.0000pt;">行政许可：</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="15" style="margin-left:24pt;text-indent:0pt;"> <span style="font-family:宋体;font-size:12.0000pt;">A</span><span style="font-family:宋体;font-size:10.5pt;background:#FFFFFF;">食品生产许可</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="15" style="margin-left:24pt;text-indent:0pt;"> <span style="font-family:宋体;font-size:12.0000pt;">B</span><span style="font-family:宋体;font-size:10.5pt;background:#FFFFFF;">食品经营许可（餐饮服务类）</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="15" style="margin-left:24pt;text-indent:0pt;"> <span style="font-family:宋体;font-size:12.0000pt;">C</span><span style="font-family:宋体;font-size:10.5pt;background:#FFFFFF;">药品零售企业经营许可</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="15" style="margin-left:24pt;text-indent:0pt;"> <span style="font-family:宋体;font-size:12.0000pt;">D</span><span style="font-family:宋体;font-size:10.5pt;background:#FFFFFF;">第三类医疗器械经营企业许可</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="15" style="margin-left:24pt;text-indent:0pt;"> <span style="font-family:宋体;font-size:12.0000pt;">E</span><span style="font-family:宋体;font-size:10.5pt;background:#FFFFFF;">第二类精神药品零售许可</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="15" style="margin-left:24pt;text-indent:0pt;"> <span style="font-family:宋体;font-size:12.0000pt;">F</span><span style="font-family:宋体;font-size:10.5pt;background:#FFFFFF;">药品经营质量管理规范认证</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;">二、投诉：</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;">三、举报：</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;">四、其他</span><span style="font-family:宋体;font-size:12.0000pt;"> </span><span style="font-family:宋体;font-size:12.0000pt;">：</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="MsoNormal"> <b><span style="font-family:宋体;font-size:12pt;">您的选择：</span></b><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> </tr> <tr> <td width="903" valign="center" colspan="6" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <b><span style="font-family:宋体;font-size:14pt;">申请事项（关键词）</span></b><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> </tr> <tr> <td width="903" valign="center" colspan="6" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;"> </span><b><span style="font-family:宋体;font-size:14pt;">内容</span></b><span style="font-family:宋体;font-size:12.0000pt;">：</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;"> </span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;"> </span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="MsoNormal"> <span style="font-family:宋体;font-size:12.0000pt;"> </span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> </tr> <tr> <td width="903" valign="center" colspan="6" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal"> <b><span style="font-family:宋体;font-size:14pt;">答复意见</span></b><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> </tr> <tr> <td width="903" valign="top" colspan="6" style="border:1.0000pt solid windowtext;"> <p class="MsoNormal" style="text-indent:182pt;"> <span style="font-family:宋体;font-size:14.0000pt;"> </span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> <p class="MsoNormal" style="margin-left:21pt;text-indent:135pt;"> <span style="font-family:宋体;font-size:12.0000pt;"> 接待人员（签字）：</span><span style="font-family:宋体;font-size:12.0000pt;"></span> </p> </td> </tr> </tbody> </table> <p class="MsoNormal"> </p>