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Address
Zip code
City
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Tel.no.
Fax no.
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VAT no.
Principal activity
Manufacturer
Distributor
Wholesaler
Provider of health care
Other
Product sector
Turnover of applicant in EUR millions
over 125
over 50
over 25
over 5
up to 5
The applicant is
the parent organisation
subsidiary or division
If applicant is a subsidiary or division:
LIC no of parent
LIC APPLICATION FORM
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