Class A Precursors Records Template
Precursor Purchased / Acquired from Domestic Supplier
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Precursor Purchased / Acquired from Domestic Supplier
- Provider's Name
- Provider's Precursor Licence Number
- Provider's Phone No.
- Provider's Address
- Street Number & Name
- City
- Province
- Postal Code
- Precursor
- Raw Material (indicate the salt)
- Preparation / Mixture (include: brand name (if any) and strength of precursor)
- DIN / NPN #
- Quantity Precursor Purchased (salt, kg)
- Date Purchased
- Purchase Order No. (where available)
- Comments
Precursor Produced
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Precursor Produced
- Precursor
- Raw Material (indicate the salt)
- Quantity of Precursor Produced (salt, kg)
- Preparation/Mixture (include: brand name (if any) and strength of precursor)
- DIN / NPN #
- Quantity Precursor used to Produce Preparation/Mixture (salt, kg)
- Date Produced
- Comments
Precursor Packaged
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Precursor Packaged
- Precursor
- Raw Material (indicate the salt)
- Preparation / Mixture (include: brand name (if any) and strength of precursor)
- DIN / NPN #
- No. of Units Packaged
- Total Precursor Packaged (salt, kg)
- Date Packaged
- Comments
Precursor Sold / Provided (Domestic Distribution)
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Precursor Sold / Provided (Domestic Distribution)
- Purchaser / Recipient
- Purchaser's Licence No. (where applicable)
- Purchase Order No. (where applicable)
- Purchaser / Recipient's Address
- Street Number & Name
- City
- Province
- Postal Code
- Phone No. (where available)
- Fax No. (where available)
- Precursor
- Raw Material (indicate the salt)
- Preparation / Mixture (include: brand name (if any) and strength of precursor)
- DIN / NPN #
- Quantity Precursor Sold / Provided (salt, kg)
- Date Sold / Provided
- Comments
Precursor Imported
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Precursor Imported
- Import Permit No.
- Precursor
- Raw Material (indicate the salt)
- Preparation / Mixture (include: brand name (if any) and strength of precursor)
- DIN / NPN #
- Quantity Precursor Imported (salt, kg)
- Date Imported
- Exporter
- Company Name
- Address
- Phone No. (where available)
- Fax No. (where available)
- Country
- Transit or Transhipment Countries
- Comments
Precursor Exported
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Precursor Exported
- Export Permit No.
- Precursor
- Raw Material (indicate the salt)
- Preparation / Mixture (include: brand name (if any) and strength of precursor)
- DIN / NPN #
- Quantity Precursor Exported (salt, kg)
- Date Exported
- Importer
- Name
- Address
- Phone No. (where available)
- Fax No. (where available)
- Country
- Transit or Transhipment Countries
- Comments
Precursor Used For Own Purposes
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Used by the licensed dealer for own purposes including:
(1) The quantity of operational loss, such as waster or loss in-process during the production of mixtures or preparations which contain that precursor (i.e. the operational loss of pseudoephedrine raw material during the production of pseudoephedrine preparations)
(2) The quantity used for quality control testing.
Precursor Used For Own Purposes
- Precursor
- Raw Material (indicate the salt)
- Preparation / Mixture (include: brand name (if any) and strength of precursor)
- DIN / NPN #
- Quantity Used (salt, kg)
- Activity
- Type
- Date
- Comments
Precursor Destroyed
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Precursor Destroyed
- Precursor
- Raw Material (indicate the salt)
- Preparation / Mixture (include: brand name (if any) and strength of precursor)
- DIN / NPN #
- Quantity Precursor Destroyed (salt, kg)
- Date Destroyed
- Name of Disposal Company
- Reason for disposal
- Method of destruction
- Witnesses
- Name of witness # 1
- Name of witness # 2
- Comments
Precursor Declaration
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Precursor Declaration
- Precursor
- Raw Material (indicate the salt)
- Preparation / Mixture (include: brand name (if any) and strength of precursor)
- DIN / NPN #
- Quantity Precursor Acquired by End User (salt, kg)
- Date Acquired
- Name of person / company acquiring the precursor
- Address
- Street Number & Name
- City
- Province
- Postal Code
- Phone No.
- Fax No.
- Specify uses for the precursor
- Comments
Suspicious Transactions
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Suspicious Transactions
- Individual
- Name
- Position
- Phone No.
- ID of the Other Party to the Transaction
- Precursor
- Raw Material (indicate the salt)
- Preparation / Mixture (include: brand name (if any) and strength of precursor)
- Quantity Precursor Acquired (salt, kg)
- Details of Transaction
- Date of Transaction
- Time of Transaction
- Method of payment
- Intended use of the precursor
- Reasons of suspicion
- Comments
Loss / Theft of Precursor
- Company Name:
- Precursor Licence Number:
- Address:
- Contact Person:
- Phone Number:
- Name of Precursor:
Loss / Theft of Precursor
- Precursor
- Raw Material (indicate the salt)
- Preparation / Mixture (include: brand name (if any) and strength of precursor)
- No. of Units Lost / Stolen
- Quantity Precursor Lost / Stolen (salt, kg)
- Details of Loss / Theft
- Footnote 1 Type of Loss
- Police Notified (Y/N)
- Health Canada Notified (Y/N)
- Date Report Submitted to Authorities
- Comments
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