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RTF Template

Landesamt für soziale Dienste Schleswig-Holstein

UNION FORMAT FOR A WHOLESALE DISTRIBUTION AUTHORISATION

1. Authorisation Number	:	DE_SH_01_WDA_2018_0005
2. Name of Authorisation Holder	:	REHAFORUM MEDICAL GmbH
3. Address(es) of Site(s)	:	Daimlerstraße 12a, Elmshorn, 25337, Germany Ramskamp 77, Elmshorn, 25337, Germany

4. Legally registered address of Authorisation Holder	:	Daimlerstraße 12a, Elmshorn, 25337, Germany
5. Scope of authorisation	:	ANNEX 1
6. Legal basis of authorisation	:
7. Name of responsible officer of the competent authority of the member state granting the wholesale distribution authorisation	:	Confidential, Confidential
8. Signature	:
9. Date	:	2018-02-28
10. Annexes attached	:	Annex 1 Scope of wholesale distribution authorisation Annex 2 (Optional) Address(es) of contract wholesale distribution sites and their authorisation number Annex 3 (Optional) Name(s) of responsible person(s) Annex 4 (Optional) Date of Inspection on which authorisation was granted Annex 5 (Optional) Additional provisions based on national requirements

ANNEX 1

SCOPE OF WHOLESALE DISTRIBUTION AUTHORISATION

Name and address of the site: REHAFORUM MEDICAL GmbH

, Daimlerstraße 12a, Elmshorn, 25337, Germany

1. MEDICINAL PRODUCTS

1.1. with a Marketing Authorisation in EEA country(s)

2. AUTHORISED WHOLESALE DISTRIBUTION OPERATIONS

2.1. Procurement

2.2. Holding

2.3. Supply

2.4. Export

Any restrictions or clarifying remarks (for all users): National legal basis of authorisation:
Section 52 a (1) German Drug Law (Arzneimittelgesetz - AMG)