A COMPLETED AND SIGNED COPY OF THIS FORM MUST

PAC REFERENCE NO COMPLETED FORM TO
PLEASE FAX COMPLETED TO TULARCITOS FAX (831)
POSTGRADUATE APPLICATION FORM THE COMPLETED FORM MAY BE

TRANSMITTAL FORM FOR A COMPLETED PUBLICATION NOTE
( PASSPORT ID COMPLETED BY PHP REV
(TO BE CLASSIFIED AS SECRET ONCE COMPLETED) ANNEXURE D

DECLARATION TO ACCOMPANY A

A completed and signed copy of this form must accompany any request for a Certificate of Pharmaceutical Product (CPP).

This form must be filled out for each individual product (name + dose form + strength + classification etc).

Please also include in a cover letter with the application form(s) and email the request to [email protected]





APPLICATION TO ACCOMPANY A REQUEST FOR A

Certificate of Pharmaceutical Product



Product Details

Trade Name of Product:      

Dose Form:      

File No: TT50-     

Strength:      

Importing (requesting) Country:      


New Zealand Sponsor name and postal address:      





Is this product currently on the market in New Zealand? Yes No


If applicable, please list any documentation that has been provided to attach to the CPP (eg, labelling):


If applicable, would you like the product data sheet attached: Yes No

NB: The product’s therapeutic product database report will only be included with the CPP for approved products.

A data sheet can only be attached for a product that has an approved data sheet.


Applicant Contact Details

Title:      

Name:      

Position:      

Phone:      

E-mail:      

Company name and postal address:      


Customer reference for invoice:      


Certificate to be sent via courier (street address required):
Yes No
(NB: an additional fee will be included on the invoice)


I declare that the above product details are correct and that the applicant is authorised to act on behalf of the New Zealand license holder to request this CPP.




Signature: _________________________________________ Date:      

October 2020 Version


030907 CONFERENCE FEEDBACK FORM COMMENTS (BASED ON 94 COMPLETED
13 MODULE COURSE FORM TO BE COMPLETED BY
19 CHECKLIST 3 DAILYWEEKLY CLEANING SCHEDULE (INITIAL WHEN COMPLETED)


Tags: completed and, completed, signed