APPLICATION FOR AN IMPORT PERMIT - Faculty of Health …
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DEPARTMENT OF HEALTH
Private Bag X828 PRETORIA 0001
Inquiries: Ms Lineo Motopi Tel.: (012) 395 8366/9197 Fax:086 632 6815/2606
APPLICATION FOR AN EXPORT PERMIT FOR
BIOLOGICAL SUBSTANCES
|Person applying for an export permit: |
|NAME | |
|RANK/POSITION |PI |
| Organisation: |
|NAME | |
|ADDRESS | |
| | |
| | |
|TEL. NO. | |FAX. NO. | |
|Specific substance(s) for which an export permit is required: |
|SUBSTANCE |QUANTITY |
|Blood |10ml x patients x visits |
|Urine | 20ml x patients x visits |
|Period during which export will take place | |
|Contact person and organisation to which the substance(s) is(are) exported: |
|NAME: PERSON | |
|NAME: ORGANISATION | |
|ADDRESS | |
| | |
| | |
|TEL. NO. | |FAX. NO. | |
|Purpose(s) for which substance(s) is(are) to be used. Although detail is not required, the specific purpose(s) must be clearly stated: |
| |
| |
SIGNATURE OF APPLICANT:………………………………..DATE:……………………….
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