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Form Approved: OMB No. 0910-0025 Expiration Date: May 31, 2010 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.

Paperwork Reduction Act Statement
Public reporting burden for this collection of information is estimated to average .09 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing, and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Food and Drug Administration CDRH (HFZ-342) <--Please DO NOT RETURN this application to this address. 2094 Gaither Road Rockville, MD 20850 "An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number."

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 only be subjected to nondestructive testing and that FDA will reimburse us for any costs of damaged parts.
1. MANUFACTURER 3. BRAND 4. MODEL a. Product 6. DATES OF AVAILABILITY: 7. COMMENTS 2. PRODUCT (i.e., TV, Microwave Oven, Medical Device, etc.) 5. CHASSIS SERIES b. Service Manual

8. LOCATION A Name and Title Street Address City, State, ZIP Code

PERSON(S) TO CONTACT REGARDING SAMPLE LOCATION B Name and Title Street Address Area Code / Telephone No. City, State, ZIP Code Area Code / Telephone No.

9. LOCATION A

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

10. LOCATION A Name and Title

NAME(S) OF PERSON(S) AUTHORIZING LOAN LOCATION B Name and Title

RETURN TO:

FOOD AND DRUG ADMINISTRATION CENTER FOR DEVICES AND RADIOLOGICAL HEALTH (HFZ-342) 2094 GAITHER ROAD ROCKVILLE, MD 20850

FORM FDA 2767 (5/07)

PREVIOUS EDITION IS OBSOLETE

PSC Graphics (301) 443-1090

EF