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Appendix D - Request for Stamping
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(PDF Version - 18 K)Request for Stamping
Submit this form with one copy of any material that is to be stamped.
The undersigned Company requests that Health Canada stamp and return a copy of the enclosed information for attachment to an International Trade Certificate (ITC).
Product Licence Number (if applicable):
Site Licence Number (if applicable):
Summary of attached information and material:
If an ITC has already been issued and stamping is now required, please provide the following information:
International Trade Certificate Number:
International Trade Certificate Security Label Number:
We certify that the attached information and material are accurate and up-to-date and that copies of this information and material are on file with Health Canada.
Name of Company
Name of Company Representative
Title of Company Representative
Signature of Company Representative
Date
This document must be sworn before a notary public.
Name
Signature (Seal)
Date
This form may be subject to revision.
