Form 6012 - Application for registration of private label product based on registered initial product

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 regard to the application and to communicate any decisions and outcomes of the application.

Why are we collecting your personal information?: We require your personal information for the purpose of contacting the applicant in regards to the application and to communicate any decisions or outcomes of the application.
Will we use or share your personal information for any other reason?: Company names are disclosed after the Pest Management Regulatory Agency (PMRA) makes a decision or outcome on an application.
What are your rights?: The Privacy Act gives you the rights of access to, correction of and protection of your personal information. You have a right complain to the Privacy Commissioner of Canada if you feel your personal information has been handled improperly. For more information about these rights, or about how we handle your personal information, please contact the PMRA Information Service.

Security notice: up to Protected B only

This site is not approved by Health Canada/Public Health Agency of Canada for storage above Protected B information. Only up to Protected B information may be stored on this site.

Instructions

About this online form

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How to work with this online form

When working with this online form, you can save it to your computer at any time by pressing the 'Save Draft' button at the bottom of the form. This will generate a draft XML file.

You can continue to work on the form in subsequent sessions by loading a draft XML file in the "Load a draft XML file" section, at the top of the form.

Once you have completed the form, press the 'Save Final' button at the bottom of the form to generate a Microsoft Word file.

Instructions for completing sections of this online form

Instruction 1

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

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Instruction 2

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

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Instruction 3

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

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Instruction 4

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.

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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 #3.

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Instruction 6

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.

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Instruction 7

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 instruction7

Load a draft XML file

To continue to work off an existing form, browse for the draft file (in XML format) here:

Initial Product ^Instruction1

Initial Product Registration Number

Initial Product Name

Initial Product Registrant Name and Address ^Instruction2

Registrant Name (Full Legal Name - No Abbreviation)

Regulatory mailing address

City / Town

Province / State

Country

Postal code / ZIP

Private Label Applicant Name and Mailing Address ^Instruction3

Company Name (Full Legal Name - No Abbreviation)

Regulatory mailing address

City / Town

Province / State

Country

Postal code / ZIP

Contact name

Job title

Phone

Fax

Email address

Submission Contact ^Instruction4

Same as Private Label Applicant Name and Mailing Address

Company Name (Full Legal Name - No Abbreviation)

Regulatory mailing address

City / Town

Province / State

Country

Postal code / ZIP

Contact name

Job title

Phone

Fax

Email address

Communication ^Instruction5

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

Would you like a copy sent to the Submission Contact?

Private Label ^Instruction6

Assigned Private Label registration number

Private Label Product Name

Guaranteed Amount of the Active Ingredient(s)

Container Material (required)

Metal
Glass
Plastic
Paper
Other

Size of container

Size range / units From

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

Declaration ^Instruction7

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 of initial product registrant’s signature

Applicant’s Signature

Date of applicant’s signature

By submitting your personal information, you are consenting to its collection, use and disclosure in accordance with the privacy notice statement.

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

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Form 6012 - Application for registration of private label product based on registered initial product

Privacy notice statement

Security notice: up to Protected B only

Instructions

About this online form

How to work with this online form

Instructions for completing sections of this online form