Please Complete Either Section A or B As Applicable.

A) Patent List Is Being Filed With Submission (please check ONE of the following):

1. NDS or;
2. SNDS
   • Change in Formulation
   • Change in Dosage Form
   • Change in Use
3. Carry Forward, in Accordance With Section 4.1(2)

B)  Newly Issued Patent^{Footnote *} for Listing Against Previously Filed Submission (please identify ONE of the following):

1. NDS Submission No.: or;
2. SNDS
   • Change in Formulation, Submission No.:
   • Change in Dosage Form, Submission No.:
   • Change in Use, SubmissionNo.:
3. Carry Forward, in Accordance With Section 4.1(2)

Medicinal Ingredient(s):

Brand Name:

Human: or Veterinary:

DIN:

Dosage Form:

Strength Per Unit:

Route(s) of Administration:

Use(s) of the Medicinal Ingredient(s):

Patent Number

Code ^{Footnote *}

Canadian Filing Date of Patent Application
(yyyy-mm-dd)

Date Granted (yyyy-mm-dd)

Expiration Date
(yyyy-mm-dd)

Name and Address for Service in Canada:

Certification: In accordance with paragraph 4(4)(f), I certify that the information included in this Patent List is accurate and that the patent on the list meets the eligibility requirements of subsection 4(2) or 4(3) of the Patented Medicines (Notice of Compliance) Regulations.

Name:

Title:

Address:

Name of Manufacturer:

Signature:

Date:

Contact:
Phone#:
Fax#:

For office use only:

Submission No.:

Date of Filing Submission:

NOC Date:

Date Originally Added:

Date Amended: