SMG 9100.1 APPENDIX 5 - Record of Committee Assignment 

DATE OF THIS RECORD

PURPOSE OF THIS RECORD
New assignment
Change of previously supplied information

NAME 
Last
First

CONTACT INFORMATION
Organizational Code
Mailing address
FDA telephone number
E-mail address

COMMITTEE ASSIGNMENT
Complete name of Activity
Parent Committee (Organization, Committee number (if applicable))
Subcommittee
Other

DATE OF ASSIGNMENT
Expiration date (if any)

TYPE OF COMMITTEE
Intergovernmental
Voluntary standards (domestic)
Voluntary standards (international)
Commodity group
Scientific/professional group

POSITION ON COMMITTEE (all that apply)
Member/Delegate/Liaison
Alternate
Chair
Other officer

FDA OU APPROVALS
Name
Signature
Date

FDA APPROVALS (if required)
	(Example, OIP approval for international activity)