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Federal Agency for Medicines and Health ProductsDG INSPECTION -Authorisations Division - Narcotics TeamEurostation IIVictor Hortaplein 40/401060 BRUSSELS
Contact: [email protected] INSPECTION/Authorisations DivisionNarcotics Team
Application form for an import or export authorisation for narcotics and/or psychotropic substances
□IMPORT □EXPORT
Number of annual licence/enrolment number:
Importer (full address) Exporter (full address)
Ministerial code(if applicable)
Quantity Description of the goods (shape, name, dose)(maximum fifteen narcotics or psychotropic substances per application, lines may be added where necessary)1
Quantity + name of anhydrous base
□For re-export
□ Intended for the Belgian market
□ IMP (Investigational Medicinal Product)
□Other (specify):
□Reagents/reference standard(s) for research:
Date of application:
Responsible person or pharmacist:
Name and signature:
Telephone number:E-mail:
1 Not applicable for an application for reference standards. A list may be added as an attachment if required.Company number: BE 0884 579 424 1 | 1