Industry Canada

Industrie Canada
FORM 2

(Subsection 5(1))
SOLEMN OR STATUTORY DECLARATION UNDER PARAGRAPH 21.04(3)(c) OF THE PATENT ACT
In the matter of an application 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);

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

(a)	sought from the patentee or, if there is more than one, from each of the patentees, namely, (name(s) of the patentee(s)), by certified or registered mail addressed to (name(s) and postal address(es) of the patentee(s) or the representative(s) of the patentee(s), if any), a licence to manufacture and sell the pharmaceutical product for export to the country or WTO Member named in the application on reasonable terms and conditions and that such efforts have not been successful; and

(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.

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

Dated at the day of , .
Signature of Applicant

IC2910e (2005)

Industry Canada

2006-05-18

Melanie Pauzé

Industry Canada