Health Canada
www.hc-sc.gc.ca
Common menu bar links
Institutional links
Authority to Sell Veterinary Drugs Fee Reduction Request and Attestation Form (For Veterinary Drugs only)
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 - 69 K)
(DOC Version - 74 K)
(WPD Version - 33 K)Contact: Submission and Information Policy Division (SIPD) Annual
DO NOT enter information on Drug Identification Numbers (DINs) which do NOT qualify for a fee reduction or DINs for which discontinuation has been requested.
I, the undersigned, certify that during the last financial year, wholesale sales of each of the drug products listed below amounted to less than $20,000 ($CDN) as follows:
Company Code :
Fiscal Year End Date: (YYYY/Month/Day)
| Drug Identification Number (DIN)1 | Product | Volume | Total Sales ($CDN) | TPD USE ONLY | TPD USE ONLY | |
|---|---|---|---|---|---|---|
Name:
Signature:
Date:
Title:
Company:
Telephone:
Fax:
Applicants must be prepared to present supporting documentation for their fee reduction.
1 List in same order as Annual Drug Notification Form or invoice product list.
