<p> Cancellation Form</p><p>MHRA General Product Licence Submission Cancellation of a Marketing Authorisation Form</p><p>Authorisation Number(s):</p><p>Marketing Authorisation Holder</p><p>Name:</p><p>Company Name:</p><p>Company Address:</p><p>Applicant</p><p>Name:</p><p>Company Name:</p><p>Company Address:</p><p>Person’s Function:</p><p>Date of Signature: (dd-mm-yyyy)</p><p>Person Authorised for Communication:</p><p>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</p><p>Date of Signature: (dd-mm-yyyy)</p><p>Signature: Comments: (Include any pending submissions to be withdrawn as a consequence of the cancellation)</p>