Drug Master File (DMF) Fee Form

Contact: Drug Master File Enquiries
Date: 2013-04-01

Drug Master File Name:

DMF Number (if issued):

Customer/Client Account Number (if issued):

DMF Company Name:

Calculation of Payment

DMF for New Registration:
× $408 Cdn = $

DMF Biannual Update:
× $184 Cdn = $

Number of Letters of Access Enclosed:
× $184 Cdn = $

Total Fee (sum of the above): $

Fees Paid by:

• Owner
• Agent
• Other -For Letter of Access Only (specify):

Method of Payment

Cheques, money orders, international bank drafts or wires should be made payable to: The "Receiver General for Canada". Cheques drawn on non-Canadian banks MUST be issued in coordination with a referenced Canadian bank (that is, referenced on cheque), otherwise they are NOT ACCEPTED.

Wire payments of fees paid in advance of the service will be accepted only when wired in CANADIAN FUNDS to:

Bank Name:
Scotiabank
Toronto Business Service Centre
40 King St., West,
Toronto, Ontario, Canada, M5H 1H1

SWIFT: NOSCCATT
Bank Number: 002
Transit Number: 47696
Beneficiary Name: HEALTH CANADA - CFOB
Beneficiary Account No: 476961242210
Description Field: 022-22879 * Also include your company name and product name, as well as your invoice number and customer number if applicable.

Please ensure all service charges, including fees charged by your bank or any intermediary banks, are covered by your payment. Health Canada is not responsible for any fees charged during the transfer process. Failure to pay the full amount outstanding will result in a balance owing on your account. Any payments sent in non-Canadian funds will be rejected. For further information on wire payment, contact Accounts Receivable at 1-800-815-0506, (613) 957-1052 or via email at AR-CR@HCSC.GC.CA. If problems occur with the transaction, please contact the Scotiabank at (416) 866-6430.

Bank Wire

• date the funds were wired
• amount of money wired (Canadian $):
• name of the bank the funds were sent from:
• a copy of the transaction receipt from your bank

Cheque / Bank Draft

Cheque / Bank Draft number:

Money Order

Credit Card

Company' Full (legal) Name:

All credit cards must be equipped to make international third party transactions.

• Drug Master File Name:
• Credit Card Type (for example Visa):
• Card Holder's Name:
• Credit Card Number (full number):
• Credit Cardholder's Address:
• Credit Cardholder's Telephone Number:
• Credit Card Expiry Date:

Mandatory, if using Credit Card option

Authorized Signature:

Please Apply the Following Credit towards the Drug Master File Fee

Customer / Client Account Number

Drug Master File Company Name

Existing Credit Amount $

Existing Credit amount to be Applied $

The undersigned certifies that payment (in Canadian currency) is enclosed for the Total Fee indicated above.

Name of Authorized Signing Official

Signature Date

(YYYY-MM-DD)

For Office Use Only

SAP Number:

Invoice Date:

Drug Master File Number:

Invoice Number: