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Designated Party Authorization Form
This HTML document is not a form. Its purpose is to display the information as found on the form for viewing purposes only. If you wish to use the form, you must use the alternate format below.
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 versions of this form when submitting it to the Natural Health Products Directorate (NHPD).
(PDF Version - 30 K)
(Word Version - 175 K)Protected when completed
Note: Only submit this document with the application when the party signing the application is a designated party acting on behalf of the applicant or licensee according to paragraph 5(b) of the Natural Health Products Regulations. A separate authorization is required for each application.
I (The Senior Official) authorize (Third party person) of (Third party company name) to file a submission with the Natural Health Products Directorate on behalf of (Applicant/Company name)
- Signature:
- Print Name:
- Title:
- Applicant/Company name:
- Date (yyyy-mm-dd):
Contact Information
- Surname:
- Mr.
- Ms.
- Dr.
- Given Name:
- Title:
- Language preferred
- English
- French
- Street/Suite/Land Location:
- City - Town:
- Province - State:
- Country:
- Postal/ZIP Code:
- Telephone No.:
- Ext.:
- Ext.:
- Fax No.:
- E-mail:
