Industry Canada

Industrie Canada
FORM 8

(Subsection 5(4))
SOLEMN OR STATUTORY DECLARATION UNDER PARAGRAPH 21.16(1)(b)

OF THE PATENT ACT
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
(a)	the total monetary value of the agreement, expressed in Canadian currency, as it relates to the pharmaceutical product authorized to be manufactured and sold is $ ; and

(b)	the number of units of the pharmaceutical product to be sold under the terms of the agreement is .

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

Dated at the day of , .
Signature of holder of authorization

IC2916e (2005)

Industry Canada

2006-05-18

Melanie Pauzé

Industry Canada