Application for Registration of Private Label Product Based on Registered Initial Product

Privacy Notice Statement
Instructions
Form

Privacy Notice Statement

Health Canada
Collection and use of personal information in this application is in accordance with the federal Privacy Act.

The personal information you provide is collected under the authority of section 6(1)(a) of the Pest Control Product Regulations for the purpose of contacting the applicant in regards to the application and to communicate any decisions and outcomes of the application.

The Privacy Act gives you the rights of access to, correction of and protection of your personal information. For further information about this Privacy statement please contact Health Canada’s Access to Information and Privacy Coordinator by email at atip-aiprp@hc-sc.gc.ca.

Instructions

Instruction 1

Initial Product Registration Number and Name

Input the registration number assigned to the Initial Product. State product name as per Initial Product Registration Certificate.

Return to instruction 1 referrer

Instruction 2

Initial Product Registrant Information

Input the name, postal address and telephone number of the registrant for the Initial Product.

Return to instruction 2 referrer

Instruction 3

Private Label Applicant Information

Input the name and postal address of the applicant, as it will appear on the label.

Return to instruction 3 referrer

Instruction 4

Canadian Agent

Applicants from outside of Canada must show the name and address of their resident Canadian agent. Canadian applicants are not required to complete this section.

Return to instruction 4 referrer

Instruction 5

Communication

Formal correspondence, including the Registration Letter, Certificate of Registration, and Approved Label text will be sent to the Regulatory Mailing address identified in #3.

Return to instruction 5 referrer

Instruction 6

Private Label Product Name, Assigned Private Label Registration Number, Guarantee, Type and Size of Container

The product name of the new private label product, which may include a distinctive brand or trademark.

Words or phrases descriptive of the purpose and physical form of the product must be included on the primary panel of the label, but do not need to be part of the product name.

Indicate registration number of the Private Label Product as assigned by the Initial Product registrant.
List the guaranteed amounts of the active ingredients by using common or chemical names as per Initial Product specifications.

Indicate the type of packaging for the product. List the sizes of containers for the product. The container size(s) and type(s) must be selected from the size(s) and type(s) approved on the Statement of Product Specification form of the Initial Product.

Return to instruction 6 referrer

Instruction 7

Declaration

Signature of Initial Product registrant acknowledging that the Private Label product will have the identical formulation and uses as the Initial Product.

Signature of applicant acknowledging that the named formulator will produce the product and that label changes must be cleared through the Pest Management Regulatory Agency. If the Initial Product registrant signs for the Private Label applicant, a letter of signature authorization from the Private Label applicant is required.

Return to instruction 7 referrer

Form

1. Initial Product ^{Instruction 1}

Initial Product Registration Number (required)

Initial Product Name (required)

2. Initial Product Registrant Name and Address ^{Instruction 2}

Registrant Name (Full Legal Name - No Abbreviation) (required)

Postal Delivery Address (required)

City / Town (required)

Province / State (required)

Country (required)

Postal Code / ZIP (required)

3. Private Label Applicant Name and Mailing Address ^{Instruction 3}

Company Name (Full Legal Name - No Abbreviation) (required)

Regulatory Mailing Address (required)

City / Town (required)

Province (required)

Country

Postal Code (required)

Contact Name (required)

Job Title (required)

Phone (required)

Fax

E-mail (account@example.com)

4. Submission Contact ^{Instruction 4}

Same as 3. Private Label Applicant Name and Mailing Address

Company Name (Full Legal Name - No Abbreviation)

Submission Contact Mailing Address

City / Town

Prov / State

Country

Postal Code / ZIP

Contact Name

Job Title

Phone

Fax

E-mail (account@example.net)

5. Communication ^{Instruction 5}

Formal correspondence, including the Registration Letter, Certificate of Registration, and Approved Label text will be sent to the Regulatory Mailing Address identified in block 3.

Would you like a copy sent to the Submission Contact identified in Block 4? Yes

6. Private Label ^{Instruction 6}

Assigned Private Label registration no.

Private Label Product Name (required)

Guaranteed Amount of the Active Ingredient(s) (required)

Container Material: (required)

Metal
Glass
Plastic
Paper
Other (specify) Enter other

Size of container

Size range / units : From to To

or Size(s) / units

Size / unit 1

Size / unit 2

Size / unit 3

Size / unit 4

Size / unit 5

Size / unit 6

Size / unit 7

Size / unit 8

Size / unit 9

Size / unit 10

Size / unit 11

Size / unit 12

Size / unit 13

Size / unit 14

Size / unit 15

7. Declaration ^{Instruction 7}

Specifications, including sources of all ingredients, will be the same for the Private Label product as for the Initial Product. The Private Label product will be made on the same production line as the Initial Product. The Private Label will differ only in product name, company address, registration number and trade dress.

Initial Product Registrant’s Signature

Date (YYYY-MM-DD) (required)

Applicant’s Signature

Date (YYYY-MM-DD) (required)

Privacy Notice By submitting your personal information, you are consenting to its collection, use and disclosure in accordance with the Privacy Notice Statement. (required) Privacy Notice Statement

Signature Please ensure that you complete the 'Signature' field either on the downloaded DOC version of the form, or on the paper version, as applicable. (required)

Search

Application for Registration of Private Label Product Based on Registered Initial Product

Table of contents

Privacy Notice Statement

Instructions

Form