Industry Canada

Industrie Canada
SCHEDULE
FORM 1
(Section 4)
APPLICATION FOR AUTHORIZATION UNDER SECTION 21.04 OF THE PATENT ACT
1.	The undersigned hereby applies for an authorization under section 21.04 of the Act.

2.	The pharmaceutical product that the undersigned intends to manufacture and sell for export under the authorization is

(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).

3.	The maximum quantity of the pharmaceutical product that the undersigned intends to manufacture and sell for export under the authorization is .

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(s) are as follows:

Name of Patentee	Name and Address of Patentee's Representative or Address of Patentee	Patent Number
(a)
(b)
(c)
(d)
5.	The name of the WTO Member or country that has notified, respectively, the TRIPS Council or the Government of Canada in writing of its requirement for the pharmaceutical product named in the application, and to which the pharmaceutical product is to be exported, is .

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:

7.	For the purpose of subsection 21.06(1) of the Act, the website address of the undersigned is

8.	The name, postal address and telephone number of the undersigned are as follows:

Dated at the day of , .
Signature of Applicant

IC2909e (2005) p.2

IC2909e (2005) p.1

Industry Canada

2006-05-18

Melanie Pauzé

Industry Canada