Form Approved: OMB No. 0910-0025

Expiration Date: May 31, 2010

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<td colspan="9"><p><strong>DEPARTMENT OF HEALTH AND HUMAN SERVICES<br />
</strong>FOOD AND DRUG ADMINISTRATION</p>
<p><strong>NOTICE OF AVAILABILITY OF SAMPLE ELECTRONIC
PRODUCT</strong></p></td>
<td><p>DATE</p>
<p>     </p></td>
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<tr class="even">
<td colspan="10">NOTE: This report is authorized by Public Law 90-602
for radiation-emitting products.</td>
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<tr class="odd">
<td colspan="10"><strong>Paperwork Reduction Act Statement</strong></td>
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<td colspan="10"><strong>Public reporting burden for this collection of
information</strong> 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:</td>
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<tr class="odd">
<td colspan="5"><p>Food and Drug Administration<br />
DRH (HFZ-342)</p>
<p>2094 Gaither Road<br />
Rockville, MD 20850</p></td>
<td colspan="5">← Please <strong>DO NOT RETURN</strong> this application
to this address.</td>
</tr>
<tr class="even">
<td colspan="10"><em>"An agency may not conduct or sponsor, and a person
is not required to respond to,<br />
a collection of information unless it displays a currently valid OMB
control number."</em></td>
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<td><blockquote>
<p>The</p>
</blockquote></td>
<td colspan="6">     </td>
<td colspan="3">agrees to provide, on a loan basis and</td>
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<td colspan="10"><blockquote>
<p>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.</p>
</blockquote></td>
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<td colspan="6"><p>1. MANUFACTURER</p>
<p>     </p></td>
<td colspan="4"><p>2. PRODUCT <em>(i.e., TV, Microwave Oven, Medical
Device, etc.)</em></p>
<p>     </p></td>
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<td colspan="4"><p>3. BRAND</p>
<p>     </p></td>
<td colspan="4"><p>4. MODEL</p>
<p>     </p></td>
<td colspan="2"><p>5. CHASSIS SERIES</p>
<p>     </p></td>
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<td colspan="4">6. DATES OF AVAILABILITY:      </td>
<td colspan="4"><p>a. Product</p>
<p>     </p></td>
<td colspan="2"><p>b. Service Manual</p>
<p>     </p></td>
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<tr class="even">
<td colspan="10"><p>7. COMMENTS</p>
<p>     </p></td>
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<td colspan="10">8. <strong>PERSON(S) TO CONTACT REGARDING
SAMPLE</strong></td>
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<td colspan="6">LOCATION A</td>
<td colspan="4">LOCATION B</td>
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<td colspan="6"><p>Name and Title</p>
<p>     </p></td>
<td colspan="4"><p>Name and Title</p>
<p>     </p></td>
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<td colspan="6"><p>Street Address</p>
<p>     </p></td>
<td colspan="4"><p>Street Address</p>
<p>     </p></td>
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<td colspan="3"><p>City, State, ZIP Code</p>
<p>     </p></td>
<td colspan="3"><p>Area Code / Telephone No.</p>
<p>     </p></td>
<td colspan="3"><p>City, State, ZIP Code</p>
<p>     </p></td>
<td><p>Area Code / Telephone No.</p>
<p>     </p></td>
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<tr class="even">
<td colspan="10">9. <strong>LOCATION(S) TO WHICH SAMPLE(S) SHOULD BE
RETURNED</strong></td>
</tr>
<tr class="odd">
<td colspan="6">LOCATION A</td>
<td colspan="4">LOCATION B</td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="4">     </td>
</tr>
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<td colspan="10">10. <strong>NAME(S) OF PERSON(S) AUTHORIZING
LOAN</strong></td>
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<tr class="even">
<td colspan="6">LOCATION A</td>
<td colspan="4">LOCATION B</td>
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<tr class="odd">
<td colspan="6"><p>Name and Title</p>
<p>     </p></td>
<td colspan="4"><p>Name and Title</p>
<p>     </p></td>
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<td colspan="2"><strong>RETURN TO:</strong></td>
<td colspan="8">FOOD AND DRUG ADMINISTRATION<br />
CENTER FOR DEVICES AND RADIOLOGICAL HEALTH (HFZ-342)<br />
2094 GAITHER ROAD<br />
ROCKVILLE, MD 20850</td>
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**FORM FDA 2767 (5/07)** PREVIOUS EDITION IS OBSOLETE PSC Graphics:
(301) 443-1090 EF