This form, when completed, will be classified as
'For official use only'.
For guidance on how your information will be treated by the
TGA see: Treatment of information provided to the TGA.
Notification of antibiotic imports (previously Antibiotic return - Form F)
Substances controlled under Regulation 5A of the Customs (Prohibited Imports) Regulations 1956.
To assist in the completion of this form, guidance is available at Licences and permits on the TGA’s website.
1.
Importer information
Importers name:
Company name:
Postal address:
Company address (if different to postal address):
2.
Declaration and consent
I declare that to the best of my knowledge all the information in this application is true, correct and complete. I am aware
that giving false or misleading information is a serious offence (see Division 136 and 137 of the Criminal Code Act 1995).
Signature of importer:
Name:
Email:
Position:
Facsimile:
Telephone:
Date:
Office use only
Received:
Receipt:
NDS Reference:
Permit:
PO Box 100 Woden ACT 2606 ABN 40 939 406 804
Phone: 02 6232 8740 Fax: 02 6203 1740 Email: dcs@tga.gov.au http://www.tga.gov.au
Sent:
Schedule 1: Details of antibiotics ‘imported’ under current permit (Include additional pages, if needed)
Permit number:
Number of pages for this permit number return:
Antibiotic name
Trade name
Manufacturer
Country of
origin
End use
Form
Quantity
Pack size
Unit size
Strength
(metric units)
E.g. Penicillin
Pentax
John’s Drugs
Liberia
human
capsules,
vials
40 packs
12 caps/
pack
50 mg tablet, 5
ml vial
100%,50 mg/
tab, 2 mg/ ml
Page(s):
of
Notification of antibiotic imports (previously Antibiotic Return - Form F) (April 2015)
For official use only
Page 2 of 2