Application Form for International Trade Certificate - for Export Only

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

For Viewing Purposes Only - Licence applicants must use the available WORD or PDF version of this form when submitting it to the Natural Health Products Directorate (NHPD).

I. HC USE ONLY
File Number	Submission Number	Date/Time of Receipt

Instructions on how to complete this application form are available further below.

II. Country of Consignment

Name of Country:

III. Applicant/Company
Applicant/Company name:		Company Code (If Known):
Street/Suite/Land Location:
City:	Province:	Country:	Postal Code:

IV. Contact Information
Surname:	Given Name:	Title:
Street/Suite/Land Location:
City:	Province:	Country:	Postal Code:
Telephone No:	Fax No:	E-Mail:

V. Product Information
Brand Name:
Recommended Use(s) or Purpose(s):	Dosage Form:
Route of Administration:	Sterile Dosage: Yes No
Medicinal Ingredients: (By common name)	Quantity/dosage unit:	Potency (If any):
Non-Medicinal Ingredients:

VI. Site Information
Authorized Activities	Site Address	Site Licence Number	Date of Expiry

VII. Attestation
	I attest that this product has been manufactured solely for export, in compliance with Section 37 of the Food and Drugs Act. It is not authorized for sale in Canada.
I, the undersigned, certify that the information in this International Trade Certificate application is accurate and complete.

_________________________ Signature of Applicant

________________ Date

Number of certificates requested:
The certificate may be returned by:
	Prepaid Courier (a completed shipping form is included with this application e.g waybill Purolator, UPS, Fedex etc.)
	Regular Mail
Certificates:
	English
	French

Instructions for Completing the Form

• I. To be completed by Health Canada.

The following information to be provided by the applicant:

• II. Country of Consignment: The importing country (e.g. Japan, Nigeria).
  
  One form must be completed for each country of consignment and separate, country-specific certificates will be issued.
  
  
• III. Applicant Information:
  
  Applicant/Company name: The legal name of the applicant or company requesting the certificate. The certificate will be issued to and will bear this name.
  
  If the applicant for the International Trade Certificate is not also the product licence holder for the specified product, a letter from the product licence holder authorizing the applicant to export the specified product must be provided.
  
  Address of Applicant/Company: The full address of the applicant in Canada. The certificate will be mailed to this address.
  
  
• IV. Contact Information: The contact person for the application, this may be an employee of the applicant company, or may be contracted from another company on behalf of the applicant.
  
  
• V. Product Information:
  
  Dosage Form: The final physical form of the natural health products which may be used by the consumer without requiring any further processing. For example: tablets, gel.
  
  Recommended Use: The therapeutic use or claim listed on the label. For example: for minor throat irritations.
  
  Sterile dosage form: A dosage form that is free from microbial contamination.
  
  Medicinal Ingredients: Listing by common name of the medicinal ingredients contained within the natural health product.
  
  Non-Medicinal Ingredients:Listing by common name of the non-medicinal ingredients contained within the natural health product.
  
  Quantity: List the quantity of the specified medicinal ingredient and if applicable, for non medicinal ingredients per dosage unit. For example: for a 500 mg tablet of Vitamin C, Quantity: 500 mg.
  
  Potency: This is the component to which the amount (amount per dosage unit which further characterizes the quantity of the ingredient) applies. For example: 5% hyperforin.
  
  
• VI. Site Information
  
  Site Licence Number: A number issued by Health Canada's Natural Health Products Directorate based on the requirements set out in the Natural Health Products Regulations as proof of authorization to conduct specified activities at the listed locations.
  
  Expiry Date: The date on which the site licence expires, if not renewed in accordance with the provisions set out in the Natural Health Products Regulations and Site Licensing Guidance Document.