e-form

Application for a Variation Notification to a Parallel Import Licence

1 DETAILS OF THE PROPOSED PARALLEL IMPORT LICENCE HOLDER (PARALLEL IMPORTER)

Name:

Address:

Country:

Telephone:

E-Mail

2 PRODUCT DETAILS

Name of the product:

Pharmaceutical form:

Strength:

Parallel import licence number:

LI001/09 Appendix 7 Version 2

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3 NATURE OF THE CHANGE

The change affects:

LI001/09 Appendix 7 Version 2

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Please specify:

Background (Please give brief background information for the proposed change to the parallel import licence):

LI001/09 Appendix 7 Version 2

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4. Declaration

I hereby apply to vary the Parallel Import Licence. I confirm that no changes have been made to the medicinal product particulars other than those notified to the Medicines Authority. I declare that all changes have been identified and that there are no other changes in the amended documentation.

Signature of applicant:

Kindly fill in the Declaration form at the following link http://www.medicinesauthority.gov.mt/onlineapplications
A Declaration form should be submitted for each signatory.

Name:

Email address:

Date:

LI001/00 Appendix 7 Version 2

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