West The Source™ 
 
 
Letter of Authorization 

Please fill out the below form to request a Letter of Authorization.  If you have any questions, please contact Mary Nugent at 610-594-3269 or by email  LOArequests@westpharma.com.

Please list your information:
* First Name:  
* Last Name:  
* Your Title:  
* Your Company Name:  
* Your Address1:  
Your Address2:
* Your City:  
Your State/Province:  
* Your Zip/Postal Code:  
* Your Country:  
* Your Telephone:  
* Your Email Address:
Would you like to receive a copy of the Letter of Authorization?
Is the Company for whom LOA is being issued the same as above?
* Company Name:  
* Company Address1:  
Company Address2:
* Company City:  
Company State/Province:  
* Company Zip/Postal Code:  
* Company Country:  
 
Would you like this Company to receive a copy of the Letter of Authorization?
The following are required if receiving a copy of the LOA
Company Contact First Name:
Company Contact Last Name:
Company Contact Title:
Company Contact Email:
 
Would you like an additional copy of the LOA sent to someone else?
Please specify their name, address and email address, if applicable:
First Name:  
Last Name:
Company Name:
Address1:
Address2:
City:
State/Province:
Zip/Postal Code:
Country:
Email Address:
WPS Product Item No.(s) and Description
* Please note - You will need to fill out a new LOA request form for each drug product sumbission.
Your Drug Product Name:
Please list each individual West Component/Item being used. You may enter up to three (3) West Component/Item(s).
* If you do not have our Item Number, please enter the formulation, configuration and any coatings, if applicable.
 
* Item No. 1:
Is this item receiving Westar RS washing process?
If yes, from which facility?
* West Item No./SAP No.:
(8 digits) Please note: If you require assistance locating your West Item number, please contact Customer Service at 1-800-231-3000.
Formulation:   e.g. (4432/50 Gray)  
Configuration (shape):   e.g. (S-127)
Coatings 1:   e.g. (Teflon 2)
Coatings 2:
Coatings 3:
Do you require a controlled drawing for this item?
If so, you must provide either the West Item No. or the West Controlled Drawing No.:
 
Item No. 2:
Is this item receiving Westar RS washing process?
If yes, from which facility?
* West Item No./SAP No.:
(8 digits) Please note: If you require assistance locating your West Item number, please contact Customer Service at 1-800-231-3000.
Formulation:   e.g. (4432/50 Gray)  
Configuration (shape):   e.g. (S-127)
Coatings 1:   e.g. (Teflon 2)
Coatings 2:  
Coatings 3:  
Do you require a controlled drawing for this item?
If so, you must provide either the West Item No. or the West Controlled Drawing No.:
 
Item No. 3:
Is this item receiving Westar RS washing process?
If yes, from which facility?
* West Item No./SAP No.:
(8 digits) Please note: If you require assistance locating your West Item number, please contact Customer Service at 1-800-231-3000.
Formulation: