NOMINATED SIGNATORIES FORM

It is the responsibility of the pharmaceutical company to ensure individuals nominated as signatories meet the qualification requirements stated in Clause 8 and its supplementary information.

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Please submit details below

NOMINATED SIGNATORIES FORM

Name and job title of employee completing this form on behalf of the pharmaceutical company *

Pharmaceutical company *

Email (this must be a pharmaceutical company email address) *

Telephone number *

I hereby give an assurance that I have checked and verified that the following signatories fulfil the requirements in accordance with Clause 8 of the Code and its supplementary information *

PLEASE UPLOAD A DOCUMENT DETAILING ALL THE NAME(S), JOBTITLE(S) AND QUALIFICATIONS OF THE COMPANY'S NOMINATED SIGNATORY(S) AS SET OUT IN CLAUSES 8.1 AND 8.2. CLEARLY INDICATE WHICH ARE AQP SIGNATORIES AS SET OUT IN CLAUSE 8.2. *

Please confirm that you have consent of all the individuals listed on the form to provide their details to the PMCPA and that you have read our privacy policy *