Class A Precursors Records Template

• Precursor Purchased / Acquired from Domestic Supplier
• Precursor Produced
• Precursor Packaged
• Precursor Sold / Provided (Domestic Distribution)
• Precursor Imported
• Precursor Exported
• Precursor Used For Own Purposes
• Precursor Destroyed
• Precursor Declaration
• Suspicious Transactions
• Loss / Theft of Precursor

Precursor Purchased / Acquired from Domestic Supplier

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

• Provider's Name
• Provider's Precursor Licence Number
• Provider's Phone No.
• Provider's Address
  • Street Number & Name
  • City
  • Province
  • Postal Code
• Precursor
  • Raw Material (indicate the salt)
  • Preparation / Mixture (include: brand name (if any) and strength of precursor)
  • DIN / NPN #
  • Quantity Precursor Purchased (salt, kg)
  • Date Purchased
  • Purchase Order No. (where available)
• Comments

Precursor Produced

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

• Precursor
  • Raw Material (indicate the salt)
  • Quantity of Precursor Produced (salt, kg)
  • Preparation/Mixture (include: brand name (if any) and strength of precursor)
  • DIN / NPN #
  • Quantity Precursor used to Produce Preparation/Mixture (salt, kg)
  • Date Produced
• Comments

Precursor Packaged

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

• Precursor
  • Raw Material (indicate the salt)
  • Preparation / Mixture (include: brand name (if any) and strength of precursor)
  • DIN / NPN #
  • No. of Units Packaged
  • Total Precursor Packaged (salt, kg)
  • Date Packaged
• Comments

Precursor Sold / Provided (Domestic Distribution)

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

• Purchaser / Recipient
• Purchaser's Licence No. (where applicable)
• Purchase Order No. (where applicable)
• Purchaser / Recipient's Address
  • Street Number & Name
  • City
  • Province
  • Postal Code
• Phone No. (where available)
• Fax No. (where available)
• Precursor
  • Raw Material (indicate the salt)
  • Preparation / Mixture (include: brand name (if any) and strength of precursor)
  • DIN / NPN #
  • Quantity Precursor Sold / Provided (salt, kg)
  • Date Sold / Provided
• Comments

Precursor Imported

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

• Import Permit No.
• Precursor
  • Raw Material (indicate the salt)
  • Preparation / Mixture (include: brand name (if any) and strength of precursor)
  • DIN / NPN #
  • Quantity Precursor Imported (salt, kg)
  • Date Imported
• Exporter
  • Company Name
  • Address
  • Phone No. (where available)
  • Fax No. (where available)
  • Country
• Transit or Transhipment Countries
• Comments

Precursor Exported

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

• Export Permit No.
• Precursor
  • Raw Material (indicate the salt)
  • Preparation / Mixture (include: brand name (if any) and strength of precursor)
  • DIN / NPN #
  • Quantity Precursor Exported (salt, kg)
  • Date Exported
• Importer
  • Name
  • Address
  • Phone No. (where available)
  • Fax No. (where available)
  • Country
• Transit or Transhipment Countries
• Comments

Precursor Used For Own Purposes

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

Used by the licensed dealer for own purposes including:

1. The quantity of operational loss, such as waster or loss in-process during the production of mixtures or preparations which contain that precursor (i.e. the operational loss of pseudoephedrine raw material during the production of pseudoephedrine preparations)
2. The quantity used for quality control testing.

• Precursor
  • Raw Material (indicate the salt)
  • Preparation / Mixture (include: brand name (if any) and strength of precursor)
  • DIN / NPN #
  • Quantity Used (salt, kg)
• Activity
  • Type
  • Date
• Comments

Precursor Destroyed

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

• Precursor
  • Raw Material (indicate the salt)
  • Preparation / Mixture (include: brand name (if any) and strength of precursor)
  • DIN / NPN #
  • Quantity Precursor Destroyed (salt, kg)
  • Date Destroyed
• Name of Disposal Company
• Reason for disposal
• Method of destruction 
• Witnesses
  • Name of witness # 1
  • Name of witness # 2
• Comments

Precursor Declaration

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

• Precursor
  • Raw Material (indicate the salt)
  • Preparation / Mixture (include: brand name (if any) and strength of precursor)
  • DIN / NPN #
  • Quantity Precursor Acquired by End User (salt, kg)
  • Date Acquired
• Name of person / company acquiring the precursor
• Address
  • Street Number & Name
  • City
  • Province
  • Postal Code
• Phone No.
• Fax No.
• Specify uses for the precursor
• Comments

Suspicious Transactions

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

• Individual
  • Name
  • Position
  • Phone No.
• ID of the Other Party to the Transaction
• Precursor
  • Raw Material (indicate the salt)
  • Preparation / Mixture (include: brand name (if any) and strength of precursor)
  • Quantity Precursor Acquired (salt, kg)
• Details of Transaction
  • Date of Transaction
  • Time of Transaction
  • Method of payment
  • Intended use of the precursor
  • Reasons of suspicion
• Comments

Loss / Theft of Precursor

• Company Name:
• Precursor Licence Number:
• Address:
• Contact Person:
• Phone Number:
• Name of Precursor:

• Precursor
  • Raw Material (indicate the salt)
  • Preparation / Mixture (include: brand name (if any) and strength of precursor)
  • No. of Units Lost / Stolen
  • Quantity Precursor Lost / Stolen (salt, kg)
• Details of Loss / Theft
  • ^{Footnote 1} Type of Loss
  • Police Notified (Y/N)
  • Health Canada Notified (Y/N)
  • Date Report Submitted to Authorities
• Comments