Application for an Exemption for Preparations and Mixtures of Class A or Class B Precursors

Under the provisions of the Controlled Drugs and Substances Act and the Precursor Control Regulations

• 1. APPLICANT
  • Name
  • Address
  • Telephone Number
  • Fax Number
  • E-Mail address
  • Licence/Registration number (if applicable)
• 2. PREPARATION OR MIXTURE
  1. Name
  2. Chemical composition
  3. Brand name
• 3. QUALITATIVE COMPOSITION
  • Class A and/or B precursor(s):
  • Other chemical ingredient(s):
  • Additional information attached
• 4. QUANTITATIVE COMPOSITION
  • Class A and/or B precursor(s):
  • Other chemical ingredient(s):
  • Additional information attached
• 5. PHYSICAL PROPERTIES
  • Preparation/Mixture:
  • Class A and/or B precursor(s):
  • Additional information attached
• 6. CHEMICAL PROPERTIES
  • Preparation/Mixture:
  • Class A and/or B precursor(s):
  • Additional information attached
• 7. ANALYTICAL METHOD FOR PURITY AND STABILITY
  • Additional information attached
• 8. INTENDED USE
  • Additional information attached
• 9. JUSTIFICATION FOR APPLYING FOR EXEMPTION, INCLUDING THE SCIENTIFIC PRINCIPLES
  (eg. Number and description of steps required to extract the precursor)
  • Additional information attached
• 10. CERTIFICATION

I hereby certify that to my understanding, the above mentioned preparation / mixture is made in such a way that the precursor in that preparation/mixture can not be readily extracted, and that preparation/mixture cannot be used in the production of a controlled substance.

I further certify that the information provided in this application form is correct and complete to my best knowledge.

• Name
• Signature
• Position
• Date

Note: Please attach additional sheet for information required in 4 to 10, if necessary.

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

Evaluation and Authorization Division
Office of Controlled Substances
Drug Strategy and Controlled Substances Programme
Healthy Environments and Consumer Safety Branch
Health Canada
123 Slater St
AL 3503B
Ottawa ON K1A 1B9

Check List to Accompany the Application Form for Exemption for Preparations and Mixtures of Class A or Class B Precursors

This check list is provided to assist you on ensuring that all the required information has been included in your application for Exemption for Preparations and Mixtures of Class A or Class B Precursors. Providing all the required information will avoid unnecessary delays in processing your application. Incomplete applications will be put on hold until the required information is received. If the latter is not received within the time period indicated, the application will be considered to have been withdrawn.

Please ensure the following information is completed in your application:

• Section 3: Information on the qualitative composition of the preparation or mixture has been included.
• Section 4: Information on the quantitative composition of the preparation or mixture has been included.
• Section 5: Information on the physical properties of the preparation or mixture has been included.
• Section 6: Information on the chemical properties of the preparation or mixture has been included.
• Section 8: Information on the intended use of the preparation or mixture has been included.
• Section 9: Information on the description and number of steps required to extract the precursor from the preparation or mixture has been included.
• Section 10: The application has been signed.