-
[...]
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2 The pharmaceutical product that the undersigned intends to manufacture and sell for export under the authorization is
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(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of theMedical Devices Regulations).
-
[...]
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4 For each patented invention to which the application relates, the name(s) of the patentee(s) of the invention, the name(s) and postal address(es) of the representative(s) of the patentee(s) or, if no representative has been appointed, the postal address(es) of the patentee(s), and the patent number(s) issued in respect of the invention are as follows:
-
[...]
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6 The name, postal address and telephone number of the person or entity referred to in paragraph 21.04(2)(f) of the Act, to which the pharmaceutical product is to be sold, are as follows:
[...]
-
[...]
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8 The name, postal address and telephone number of the undersigned are as follows:
[...]
[...]
In the matter of an application by 
[...]
(name of country or WTO Member) of the following pharmaceutical product:
-
(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of theMedical Devices Regulations);
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1 The undersigned
(name of applicant) hereby declares, in accordance with paragraph 21.04(3)(c) of the Act, that on
(date), being at least 30 days before the date of filing of the application for an authorization under section 21.04 of the Act, the undersigned
-
[...]
-
(b) provided the patentee, or each of the patentees, as the case may be, by certified or registered mail, in the written request for a licence, with the information that is in all material respects identical to the information required under paragraphs 21.04(2)(a) to (g) of the Act.
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2 The name, postal address and telephone number of the undersigned are as follows:
[...]
[...]
In the matter of an application by 
(name of applicant) for export to
(name of WTO Member) of the following pharmaceutical product:
-
(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of the Medical Devices Regulations);
[...]
In the matter of an application by 
[...]
(name of WTO Member) of the following pharmaceutical product:
-
(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of the Medical Devices Regulations);
[...]
In the matter of an application by 
[...]
(name of country) of the following pharmaceutical product:
-
(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of the Medical Devices Regulations);
[...]
In the matter of an application by 
[...]
(name of country) of the following pharmaceutical product:
-
(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of the Medical Devices Regulations);
[...]
In the matter of an application by 
[...]
(name of country or WTO Member) of the following pharmaceutical product:
-
(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of the Medical Devices Regulations);
-
1 The undersigned
(name of applicant) hereby declares, in accordance with clause 21.04(3)(d)(iii)(A), (iv)(A) or (v)(A) of the Act, as the case may be, that the pharmaceutical product to which the application relates is not patented in the country or WTO Member.
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2 The name, postal address and telephone number of the undersigned are as follows:
[...]
[...]
In the matter of authorization number
granted on
(date) to
(name of holder of authorization) for export to
(name of country or WTO Member) of the following pharmaceutical product:
-
(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of the Medical Devices Regulations);
-
1 The undersigned
(name of holder of authorization) hereby declares, in accordance with paragraph 21.16(1)(b) of the Act, that
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2 The name, postal address and telephone number of the undersigned are as follows:
[...]
[...]
In the matter of application for authorization number
by
(name of applicant) for export to
(name of country or WTO Member) of the following pharmaceutical product:
-
(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of the Medical Devices Regulations);
[...]
In the matter of an application for renewal of authorization by
(name of applicant) for export to
(name of country or WTO Member) of the following pharmaceutical product:
-
(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of the Medical Devices Regulations);
-
[...]
-
2 For each patented invention to which the application for renewal relates, the name(s) of the patentee(s) of the invention, the name(s) and postal address(es) of the representative(s) of the patentee(s) or, if no representative has been appointed, the postal address(es) of the patentee(s), and the patent number(s) issued in respect of the invention are as follows:
[...]
In the matter of an application for a renewal of an authorization by
(name of applicant) for export to
(name of country or WTO Member) of the following pharmaceutical product:
-
(a) if the pharmaceutical product is a drug as defined in section 2 of the Food and Drugs Act: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act and, if applicable, the strength, dosage form and route of administration of the pharmaceutical product); or
-
(b) if the pharmaceutical product is a medical device: 
[...]
(name of the pharmaceutical product as set out in Schedule 1 to the Act, its class, and its identifier within the meaning of section 1 of the Medical Devices Regulations);
[...]