 ; @endphp)
REACH JOINT SUBMISSION FORM (JSF)
@php echo $data->cas_name; @endphp(CAS No: @php echo $data->cas_no; @endphp; EC No: @php echo $data->ec_no; @endphp)
Lead Registrant(LR):Global Product Compliance(GPC)
By signing this form you indicate an interest to become a joint submission member to the REACH Registration of the substance indicated below.Joint Registration Format has no binding on the timing of registration or registration itself, but its a important information for LR to make various projections and also to cut short time at later date when SIEF member decides to register.
Substance Information
Name:@php echo $data->cas_name; @endphp
CAS No:@php echo $data->cas_no; @endphp
EC No:@php echo $data->ec_no; @endphp
See Substance Identity Profile (SIP) attached for details about substance identity.
Registrant Company Details:
| Registering Legal Entity name: | @php echo $data->entity_name; @endphp | |
|---|---|---|
| UUID: | @php echo $data->uuid; @endphp | |
| Postal Address: | @php echo $data->address; @endphp | |
| Postal Code: | @php echo $data->code; @endphp | |
| Postal City: | @php echo $data->city; @endphp | |
| Country: | @php echo $data->country; @endphp |
Additional Affiliate(s) that will also register:
| Legal Entity name: | @php echo $data->rc_l_entity; @endphp (if applicable) |
|---|---|
| UUID: | @php echo $data->rc_uuid; @endphp (if applicable) |
Registerant Contact details:
| Contact Person: | @php echo $data->contact_person; @endphp (if applicable) |
|---|---|
| E-mail address: | @php echo $data->e_mail; @endphp (if applicable) |
| Telephone: | @php echo $data->telephone; @endphp (if applicable) |
Registerant Billing details:
| VAT number / TAX number: | @php echo $data->vat; @endphp |
|---|---|
| Billing Company Name: | @php echo $data->billing_company; @endphp(if diffrent from above) |
| Billing Address: | @php echo $data->billing_address; @endphp(if diffrent from above) |
| Postal Code: | @php echo $data->postal_code; @endphp(if diffrent from above) |
| Postal City: | @php echo $data->rc_city; @endphp(if diffrent from above) |
| Country: | @php echo $data->rc_country; @endphp(if diffrent from above) |
| Additional required payment data(e.g. Purchase order if required): | @php echo $data->additional_data; @endphp(if diffrent from above) |
| UUID: | @php echo $data->rb_uuid; @endphp(if diffrent from above) |
Registerant Bank account details:
| IBAN: | @php echo $data->iban; @endphp |
|---|---|
| Account Number: | @php echo $data->routing_num; @endphp |
| Bank Name: | @php echo $data->bank_name; @endphp |
| BIC/SWIFT Code: | @php echo $data->bic; @endphp |
| Payment Method: | @php echo $data->payment_method; @endphp |
| Description to be added(if required): | @php echo $data->description; @endphp |
| Additional Required payment data(if required): | @php echo $data->addtitional_requirement; @endphp |
Inputs for preparing the SIEF Agreement:
| Signing Authority: | @php echo $data->signing_person; @endphp |
|---|---|
| Function/Title: | @php echo $data->function; @endphp |
Scope of registration & dossier type:
| @php echo $data->scope; @endphp |
|---|
Year of registration:
| @php echo $data->year; @endphp |
|---|
Only Representative:
| Registering as Only Representative | @php echo $data->registering; @endphp |
|---|
Non-EU Manufacturer data(Only to be filled out if registering as only Representative):
| Legal Entity Name: | @php echo $data->non_eu_entity; @endphp |
|---|---|
| Postal Address: | @php echo $data->non_eu_add; @endphp |
| Postal Code: | @php echo $data->non_eu_code; @endphp |
| Postal City: | @php echo $data->non_eu_city; @endphp |
| Country: | @php echo $data->non_eu_country; @endphp |
For Completion of SIEF Agrement:
| Name of signing person: | @php echo $data->non_eu_signing_person; @endphp |
|---|---|
| Function/Title: | @php echo $data->non_eu_title; @endphp |
By signing this joint submission form I hereby declare that my company intends to become a joint submission memeber to the REACH Registration of the subject substance indicated above by the LR.
Signature:
| By: | @php echo $data->sign; @endphp |
|---|---|
| Function/ Title: | @php echo $data->title; @endphp |
| Date: | @php echo $data->date; @endphp |