MHRA General Product Licence Submission
Total Page：16
File Type：pdf, Size：1020Kb
Cancellation Form
MHRA General Product Licence Submission Cancellation of a Marketing Authorisation Form
Authorisation Number(s):
Marketing Authorisation Holder
Name:
Company Name:
Company Address:
Applicant
Name:
Company Name:
Company Address:
Person’s Function:
Date of Signature: (dd-mm-yyyy)
Person Authorised for Communication:
I can confirm that I understand this Product(s) covered by this Marketing Authorisation(s) once cancelled cannot be marketed, and a new application for the licence will be required at the appropriate fee should the MAH decide they wish to market it again
Date of Signature: (dd-mm-yyyy)
Signature: Comments: (Include any pending submissions to be withdrawn as a consequence of the cancellation)