UNDER THE Medical Devices Regulations
I, , certify that I have knowledge of all matters contained in this certificate and that
1 I am (check applicable box)
(a) where the medical device described in this certificate is exported by a corporation
- the exporter’s senior executive officer,
- the exporter’s senior regulatory officer,
- the authorized agent of the exporter’s senior executive officer, or
- the authorized agent of the exporter’s senior regulatory officer; and
(b) where the medical device described in this certificate is exported by an individual
- the exporter, or
- the exporter’s authorized agent.
, (State name and address of exporter or, if a corporation, name and address of principal place of business in Canada).
2 On the day of , , a package containing (description of device, including serial number, model name, lot number and quantity, as applicable; if additional space required, attach as Appendix “A”) is/will be consigned to (name and address of consignee).
3 The package is marked in distinct overprinting with the word “Export” or “Exportation”.
4 The medical device was not manufactured for consumption in Canada.
5 The medical device is not sold for consumption in Canada.
6 The package and its contents do not contravene any known requirement of the law of the country of (state country of consignee).
7 All relevant information is contained in this certificate and no relevant information has been knowingly withheld.
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