Health Canada
www.hc-sc.gc.ca
Common menu bar links
Foreign Site Reference Number Application 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.
(PDF Version - 78 K)Health Canada Use Only
1. Submission Number
2. File Number
3. Date/Time of Receipt
A. Applicant
4. Applicant/Company Name*
5. Company Code (If known)
6. Address: Street/Suite/PO Box*
7. City – Town*
8. Province/State*
9. Country*
10. Postal Code/ Zip Code*
B. Senior Official (This is the name of the principal contact person for the applicant/company)
11. Name
- Mr.
- Ms.
- Dr.
12. Title
13. Language preferred:
- English
- French
14. Company Name (*if different from Applicant/Licensee)
15. Address same as “A”
16. Street/Suite/PO Box*
17. City – Town*
18. Province/State*
19. Country*
20. Postal Code/Zip Code*
21. Telephone No.*
Ext.
22. Fax No.
23. E-mail
C. Contact For This Application (This is the contact person for this application)
24. Contact same as “B”
25. Title
26. Language preferred:
- English
- French
27. Name
- Mr.
- Ms.
- Dr.
Surname*
Given Name*
28. Telephone No.*
Ext.
29. Fax No.
30. E-mail
D. Submission Type
31. Indicate the type of application (*select one only)
- New Application*
- GMP Evidence (Information Update)*
- GMP Evidence Renewal*
REF#
E. Building Information
32. Address
34. City:
35.Country
36.Postal Code
37. Activity Type:
Manufacturing
- Add
- Delete
- Sterile Dosage
- Homeopathic Medicines
Packaging
- Add
- Delete
- Sterile Dosage
- Homeopathic Medicines
Labelling
- Add
- Delete
- Sterile Dosage
- Homeopathic Medicines
38. Evidence Type:
- Quality Assurance Report
- Supplementary Quality Assurance Report (HM)
- 3rd Party Audit Report
- Other (TGA, FDA, etc.)
39. Quality Assurance Person:
Name
Telephone Number
F. Attestation
“I attest that the building(s) , practice(s), procedure(s) used for conducting activities in all facilities listed on this application comply with the good manufacturing practice requirements outlined in Part 3 of the Natural Health Products Regulations.
40. Name of Authorized Senior Official
41. Signature*
Date yyyy/mm/dd
