Application for a Class A Precursor Licence

1. Applicant's Name

(if the applicant is a corporation, corporate name and any other name registered with a province and any other trade name under which the applicant intends to carry out the activities set out in the licence or intend to indentify itself)

• Name
• Other names

2. Licence Number

(This is the number of the licence to be renewed)

3. Preferred Language of Communication

• Verbal:
  • English
  • French
• Written:
  • English
  • French

4. Licensed Site

• 4A If the applicant intends to conduct licensed activities at more than one site, a separate application must be made for each site. If applicable, include the establishment licence number issued under section C.01A.008 of the Food and Drug Regulations or the site licence number issued under sections 29 or 36 of the Natural Health Products Regulations.
  • Licensed site
    • Street Address
    • City
    • Province
    • Postal Code
    • E-Mail Address
    • Telephone No.
    • Facsimile No.
    • Establishment or Site Licence No.
• 4B. If the mailing address is different from the Iicensed site address.
  • Mailing Address
    • Street Address
    • City
    • Province
    • Postal Code
    • E-Mail Address
    • Telephone No.
    • Facsimile No.
• 4C. Building Information

  If the site is comprised of more than one building, and the building information is different than stated above, please list on a separate sheet the address, telephone number, fax number, email address and postal address for each building within the site where precursor activity takes place.

5. Business Information

Attach a detailed description of the nature of business conducted or intended to be conducted. Also include the length of time, if any, the applicant has been in business. If applicable, include a copy of the certificate of incorporation and any document filed with the province in which the applicant is located that states the applicant's corporate name and any other name registered with the province under which the applicant will carry out the activities set out in the licence or will identify itself.

• Nature of Business

Note: Please submit additional pages if needed.

6. List of Class a Precursor and Activity to Be Licensed

• 6A. Class A Precursor Information
  
  
  • There are no changes to the information previously submitted for this section.

  List the name of each precursor sought to be licensed and for each precursor listed please specify the activity that is sought to be licensed. If applicable, include the drug identification number assigned under section C.01.014.2 of the Food and Drug Regualtions or the product number assigned under section 8 of the Natural Health Products Regulations.

  • Licence Amendment/Renewal

    In the case of a licence amendment or renewal, if the licensed dealer wants to add or delete a precursor or an activity, please fill out the table below. In the case of a deletion of a precursor, only the name of the precursor as it appears on the licence is required.

    • Addition / Deletion
    • Name of the precursor (If applicable, the name of the salt )
    • Activity(ies) related to that precursor
      • Produce
      • Package
      • Provide/Sell
      • Import
      • Export
    • Name(s) of the preparation(s)/ mixture(s) and brand name(s), if applicable
    • Drug Indentification Number or Product Number, if applicable

  Note: Please submit additional pages if needed.

• 6B. Suppliers and Clientele

  Attach the name(s) of the supplier(s) from whom you will obtain the precursor and list the type(s) of clientele to whom you intend to supply the precursor(s).

  • Name of the precursor (If applicable, the name of the salt)
  • Name(s) of supplier(s) (If applicable)
  • Type(s) of clientele

  Note: Please submit additional pages if needed.

7. Designated Personnel

A Criminal Record Check must be done for the following persons, when applying for a new licence, and when renewing a licence (even if the personnel remains unchanged).

• 7A. SENIOR PERSON IN CHARGE (SPIC):
  • Surname (Married & Maiden)
  • Given Name
  • Middle Name(s)
  • Gender
    • M
    • F
  • Date of Birth (YYYY/MM/DD)
  • Title of Position
  • Telephone No.
  • Facsimile No.
  • E-mail Address
    
  • Criminal Record Check:
    • Option 1 : Attach the original criminal record check certificate issued by a Canadian police force, and if the individual resided in another country in the previous ten years, a criminal record check document issued by a police force in that country.
    • Option 2 : Complete Section 7D allowing Health Canada to initiate criminal record check through the RCMP.
• 7B. RESPONSIBLE PERSON IN CHARGE (RPIC):
  • Surname (Married & Maiden)
  • Given Name
  • Middle Name(s)
  • Gender
    • M
    • F
  • Date of Birth (YYYY/MM/DD)
  • Title of Position
  • Telephone No.
  • Facsimile No.
  • E-mail Address
    
  • Criminal Record Check:
    • Option 1 : Attach the original criminal record check certificate issued by a Canadian police force, and if the individual resided in another country in the previous ten years, a criminal record check document issued by a police force in that country.
    • Option 2 : Complete Section 7D allowing Health Canada to initiate criminal record check through the RCMP.
• 7C. ALTERNATE PERSON IN CHARGE (A/RPIC), IF ANY:
  • Surname (Married & Maiden)
  • Given Name
  • Middle Name(s)
  • Gender
    • M
    • F
  • Date of Birth (YYYY/MM/DD)
  • Title of Position
  • Telephone No.
  • Facsimile No.
  • E-mail Address
    
  • Criminal Record Check:
    • Option 1: Attach the original criminal record check certificate issued by a Canadian police force, and if the individual resided in another country in the previous ten years, a criminal record check document issued by a police force in that country.
    • Option 2: Complete Section 7D allowing Health Canada to initiate criminal record check through the RCMP.

  Note: If more than one A/RPIC is proposed by the applicant, please submit required information on a separate sheet.

• 7D. CONSENT FOR CRIMINAL RECORD CHECK

  If any of the personnel listed in 7(A),(B) or (C) has chosen option 2, indicating consent to having a criminal record check carried out for them by the RCMP through Health Canada with respect to a designated drug offence and a designated criminal offence, they must sign in the areas indicated below.

  • Signature(s)
    • SPIC
    • RPIC
    • A/RPIC-1
  • Category of Information for Disclosure and Authorized Consent

    Records of criminal convictions found in the Identification Data Bank attainable through the Canadian Police Information Centre (CPIC) for which a pardon has not been granted.

    I agree to provide any information and submit to any means of identification* required to obtain the criminal record check.

    I agree to pay the fees established by the RCMP under the Criminal Record Verification for Civil Purposes Fee Regulations.

* If inconclusive data is obtained, i.e. unable to confirm the identity of the applicant through the name check, fingerprints will be requested.

Note: If more than one A/RPIC is proposed by the applicant, please submit required information on a photocopy of this page

8. Proposed Security Measures

• There are no changes to the information previously submitted for this section.

Provide a detailed description of the proposed security measures to be used at the site and when a precursor is sent, transported or delivered, including a description of the access log and the method by which access to the precursor is controlled.

• Description of security measures

Note: Please submit additional pages if needed.

9. Internal Controls

• There are no changes to the information previously submitted for this section.

Provide a detailed description of the internal controls proposed with respect to the Class A precursor activity at the site, including such information as the maintenance of documentation, records and books. Also, describe the system that will be used to submit your annual reports and describe what procedures will be in place for end-use declarations (if applicable), recording of suspicious transactions and reporting the loss and theft of precursors.

• Description of internal controls

Note: Please submit additional pages if needed.

10. Declaration(s)

I hereby certify that I have not, as an adult, been convicted, in the previous ten (10) years, of a designated drug offence or a designated criminal offence in Canada nor in any country other than Canada, of an offence that would have constituted a designated drug offence or a designated criminal offence if committed in Canada.

I hereby certify that I have sufficient knowledge of the provisions of the Controlled Drugs and Substances Act and the Precursor Control Regulations that apply to the licence, and have sufficient knowledge concerning the use and handling of Class A precursors to which the licence applies, including the risk of those precursors being diverted to an illicit market or use.

• 10A. Name of Senior Person in Charge (SPIC):
  • Signature:
  • Date (YYYY/MM/DD):
• 10B. Name of the Responsible Person In Charge (RPIC):
  • Signature:
  • Date (YYYY/MM/DD):
• 10C. Name of the Alternate Responsible Person In Charge (A/RPIC):
  • Signature:
  • Date (YYYY/MM/DD):

Note: If more than one A/RPIC is proposed by the applicant, please submit required information on a photocopy of this page

11. Statement

I hereby certify that the information and supporting documents provided are correct and complete to the best of my knowledge, and in accordance with the relevant sections of the Controlled Drugs and Substances Act (CDSA) and the Precursor Control Regulations (PCR).

I hereby certify that I am in a position of authority with respect to binding the applicant.

• Name of Senior Person in Charge (SPIC) :
• Signature:
• Date (YYYY/MM/DD):

Checklist for the Application for a Class a Precursor Licence

This check list is provided to ensure that all the required information has been included and that the application form has been completed.

• Section 4: information for each site has been included, including the Establishment or Site Licence Number, if applicable. (Section 14 of the PCR)
• Section 5: a description of the nature of your business is provided, as well as the length of time you have been in business. (Section 14 of the PCR)
• Section 6A: included the name of the preparation/mixture, brand name and Drug Identification Number (DIN) or Product Number, if applicable. (Section 14 of the PCR)
• Section 6B: included the names of suppliers and listed types of clientele for all precursors. (Section 14 of the PCR)
• Sections 7A to C: for each designated personnel, one of Option 1 or Option 2 has been selected. (Section 14 of the PCR)
• Section 7D: each of the designated personnel have signed in the appropriate box when option 2 has been selected in section 7A, 7B, or 7C. (Section 14 of the PCR)
• Section 8: information has been included pertaining to the access log, the method of controlling access to the precursors, and safekeeping at the site and during transportation. (Section 85, 83, and 9 of the PCR)
• Section 9: information has been included pertaining to records and books, maintenance of documentation, end-use declarations, loss and theft reporting, and the annual reporting procedure. (Section 85, 90, and 87 of the PCR)
• Section 10A: signed by the Senior Person in Charge (SPIC). (Section 14 of the PCR)
• Section 10B: signed by the Responsible Person in Charge (RPIC). (Section 14 of the PCR)
• Section 10C: signed by the Alternate Responsible Person in Charge (A/RPIC), if applicable. (Section 14 of the PCR)
• Section 11: signed by the Senior Person in Charge (SPIC). (Section 14 of the PCR)
• A copy of the Certificate of Incorporation is attached and any document filed with the province stating the applicant's corporate name and any other name registered with a province (if applicable). (Section 14 of the PCR)
• Original Criminal Record Check Certificates are attached, if applicable. (Section 14 of the PCR)

Please return the completed application form with all required documents to:

Chemical Precursors Section
Office of Controlled Substances
Health Canada
A.L. 0300B
Ottawa ON K1A 0K9