┌─────┬────┬──┬─┬────┬─┬──┬──────┐
│姓名      │        │性别│  │职务    │  │职称│            │
├─────┴────┼──┴─┴────┴─┴──┴──────┤
│身份证号码          │                                          │
├──────────┼─────────────────────┤
│执业药师注册证号码  │．                                        │
├──────────┼─────────────────────┤
│执业药师资格证书号码│                                          │
├────┬─────┴───┬────┬────────────┤
│执业类别│                  │执业地区│                        │
├────┼─────────┼────┼────────────┤
│执业单位│                  │执业范围│                        │
├────┴─────────┴────┴────────────┤
│注销注册理由：                                                  │
│                                                                │
│                                                                │
│                                                                │
│                                                                │
│                                                                │
│                                                                │
├────────────────────────────────┤
│提出注销注册单位意见：                                          │
│                                                                │
│                                                                │
│                                                                │
│                                                                │
│    负责人                                          （公章）    │
│                                                   年  月  日   │
├────────────────────────────────┤
│省级药品监督管理局意见：                                        │
│                                                                │
│                                                                │
│                                                                │
│    负责人                                          （公章）    │
│                                                   年  月  日   │
├─┬──────────────────────────────┤
│备│                                                            │
│  │                                                            │
│注│                                                            │
└─┴──────────────────────────────┘
注：本表一式四份，报送国家药品监督管理局一份。