Industry Canada

Industrie Canada
FORM 6

(Subsection 5(2))
SOLEMN OR STATUTORY DECLARATION UNDER CLAUSE 21.04(3)(d)(ii)(B)

OF THE PATENT ACT
In the matter of an application by (name of applicant) for export to (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);

1.	The undersigned (name of applicant) declares, in accordance with clause 21.04(3)(d)(ii)(B) of the Act, that the pharmaceutical product to which the application relates is the pharmaceutical product that is specified in the notice in writing that the country has provided to the Government of Canada.
2.	The name, postal address and telephone number of the undersigned are as follows:

Dated at the day of , .
Signature of Applicant

IC2914e (2005)

Industry Canada

2006-05-18

Melanie Pauzé

Industry Canada