FDA 2767 Notice of Availability of Sample Electronic Product

Form Approved: OMB No. 0910-0025
Expiration Date: January 31, 2017
DATE

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION

NOTICE OF AVAILABILITY OF SAMPLE ELECTRONIC PRODUCT
NOTE: This report is authorized by Public Law 90-602 for radiation-emitting products.

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The
agrees to provide, on a loan basis and for
a period of three to six months, the model(s) listed below for the purposes of compliance testing to the
applicable FDA standard or in the case of medical devices, the applicable voluntary standard(s) specified
in the attached letter. It is our understanding that the product(s) will be subjected to nondestructive testing
only and that FDA will reimburse us for any costs of damaged parts.
1. MANUFACTURER

2. PRODUCT (i.e., TV, Microwave Oven, Medical Device, etc.)

3. BRAND

6. DATES OF AVAILABILITY:

4. MODEL

5. CHASSIS SERIES

a. Product

b. Service Manual

7. COMMENTS

8.

PERSON(S) TO CONTACT REGARDING SAMPLE
LOCATION B

LOCATION A
Name and Title

Name and Title

Street Address

Street Address

City, State, ZIP Code

Area Code / Telephone No.

9.

City, State, ZIP Code

Area Code / Telephone No.

LOCATION(S) TO WHICH SAMPLE(S) SHOULD BE RETURNED
LOCATION A

10.

LOCATION B

NAME(S) OF PERSON(S) AUTHORIZING LOAN
LOCATION A

Name and Title

RETURN
TO:

LOCATION B
Name and Title

Food and Drug Administration
Center for Devices and Radiological Health
10903 New Hampshire Ave., Document Mail Center - WO66-G609
Silver Spring, MD 20993-0002

FORM FDA 2767 (5/14)

PREVIOUS EDITION IS OBSOLETE

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