February 2015 version
Request for Removal of Manufacturing, Testing or Packing Site from Therapeutic
Product Database Report
This form is to be used when requesting the removal of a manufacturing, testing or packing site from the
Therapeutic Product Database Report when not submitted as part of a Changed Medicine Notification.
Medicine: (Trade name, dose form, strength)
File No:
TT50-
Sponsor: (Name and postal address)
Name:
Address:
Site to be removed:
Function:
Submitted by:
Name:
Phone:
E-mail:
I confirm that there is no further stock, currently marketed or stockpiled for future sale or use in
New Zealand, either manufactured at or using any ingredients sourced from the site(s) required to
be removed.
Note: A site cannot be removed until all stock manufactured, tested or packed at the site has been
depleted from the New Zealand market.
Signature: ________________________________________________
(Sponsor or authorised agent)
Date: