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U.S. Department of Health and Human Services

For Industry

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PDUFA Dear Colleague Letter for 2004 - Attachment A

Our files show the contact person, address, and telephone number below for all correspondence, invoices, and inquiries for your firm pertaining to user fees under the PDUFA. Please make corrections below. Please complete the information, confirm that the information presented is correct and sign, date, and return this page to us.

Name Of Firm:

Address Of Firm:

Attention:

Title

Phone:

Facsimile:

E-Mail Address:

Tax ID Number:

Signature:

Title:

Date: