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Right to Sell Drugs Fee Remission Request and Attestation Form
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(Wordperfect Version - 37 K)Contact: Submission and Information Policy Division - Drug Identification Number
DO NOT enter information on Drug Identification Numbers (DINs) which do NOT qualify for a fee remission or DINs for which discontinuation has been requested.
I, the undersigned, certify that during the last calendar year, 1.5% of the actual gross revenue from sales ($CDN) of each of the drug products listed below amounted to less than the current right to sell fee* for human drug products.
*In the case of deferred fees, 1.5% of the actual gross revenue earned in the first complete calendar year on the market should amount to less than the right to sell fee that was applicable at the time of deferral
Company Code:
Calendar Year End Date:
(YYYY/Month/Day)
- DIN 1
- Product
- Volume
- Actual Gross Sales ($CDN)
Name:
Signed:
Date:
Title:
Company:
Telephone:
Fax:
Applicants must be prepared to present supporting documentation for their fee remission.
1 List in same order as Annual Drug Notification form or invoice product list.
Created : May 1998
Revised : May 2011
