Variation Application to a Manufacturer's Importer's or Wholesale Dealer's Licence
THIS APPLICATION RELATES TO: (PLEASE TICK ACCORDINGLY)
Licence holder name:
Licence Holder address
Site Name / Number:
Number of Licence being varied:
This document is not valid without all the number of pages specified. PUBLIC
IN001/10 Appendix 5 Version 1
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Name of Manufacturer, Importer or Wholesaler (if different to that of licence holder):
Address of Manufacturer, Importer or Wholesaler (if different to that of licence holder):
A MANUFACTURER’S LICENCE (PLEASE TICK ACCORDINGLY)
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B IMPORTER’S LICENCE (PLEASE TICK ACCORDINGLY)
IN001/10 Appendix 3 Version 1
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C WHOLESALE DEALER’S LICENCE (PLEASE TICK ACCORDINGLY)
(Specify the precise present and proposed wording underlining or highlighting the changed words.)
Background (Please give brief background explanation for the proposed changes to your licence).
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I hereby make application for the above Manufacturer’s, Importer’s and/or Wholesale Dealer’s Licence to be varied in accordance with the proposals given above and certify that the changes will not adversely affect the quality, efficacy or safety of any medicinal product on the premises. I declare that amended documents have been supplied and that the supporting information is correct. I declare that all changes have been identified and that there are no other changes in the amended documentation.
*Licence Holder Signature:
Kindly fill in the Declaration form at the following link http://www.medicinesauthority.gov.mt/onlineapplicationsA Declaration form should be submitted for each signatory.
Name & Surname:
Status (Job title):
* In case of a company the legal & judicial representative of the company. Please submit copy of a recent Memorandum of Articles issued by MFSA in support of this.
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