Operator:

Name:_______________________________________________________________

Address:_____________________________________________________________

Name of the responsible medical director/pharmacist:_________________________

Title:_________________________________________________________________

Phone No.___________________________ Fax No._________________________

Requests the supplier:⁵⁴

⁵⁴If the operator is exporting directly from its emergency stock, it should be considered as a supplier.

Name:_____________________________________________________________

Address:___________________________________________________________

Responsible pharmacist:_______________________________________________

Phone No.________________________ Fax No.___________________________

For an emergency shipment⁵⁵ of the following medicine(s) containing controlled substances:

⁵⁵Emergency deliveries do not affect the estimate of the recipient country since they have already been accounted for in the estimate of the exporting country.

Name of product (in INN/generic name) and dosage form, amount of active ingredient per unit dose, number of dosage units in words and figures

Narcotic drugs as defined in the 1961 Convention (e.g. morphine, pethidine, fentanyl) [e.g. Morphine injection 1 ml ampoule; morphine sulfate corresponding to 10 mg of morphine base per ml; two hundred (200) ampoules]

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Psychotropic substances as defined in the 1971 Convention (e.g. buprenorphine, pentazocine, diazepam, phenobarbital)

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Others (nationally controlled in the exporting country, if applicable)

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

To the following recipient (whichever applicable):

Country of final recipient:__________________________________________________

Responsible person for receipt:_____________________________________________

Name:_________________________________________________________________

Organization/Agency:_____________________________________________________

Address:_______________________________________________________________

Phone No. ________________________________ Fax No._______________________

For use by/delivery to:

Consignee (If different from above e.g. transit in a third country):

Name:______________________ Organization/Agency____________________________

Address:__________________________________________________________________

Phone No._______________________ Fax No.___________________________________

Nature of emergency (Brief description of the emergency motivating the request):

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Availability of, and action taken to contact the control authorities in the receiving country:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

I certify that the above information is true and correct. My Organization will:

- Take responsibility for receipt, storage, delivery to the recipient/end-user, or use for emergency care (strike out what is not applicable) of the above controlled medicines;

- Report the importation of the above controlled medicines as soon as possible to the control authorities (if available) of the receiving country;

- Report the quantities of unused controlled medicines, if any, to the control authorities of the receiving country (if available), or arrange for the end-user to do so (strike out what is not applicable).