final report, of those trials to this application, as may be applicable. (This may be in the investigators brochure).
LETTER OF AUTHORIZATION FROM HOLDER OF PATENT OF ECTOPARASITICIDE, LICENCED PERSON OR MANUFACTURER OF ECTOPARASITICIDE
Dae: ……………………………………………………………..……………. (Name of holder of patent, licensed person or manufacturer)…………………. ……………………………………………...………………………………….. a company operating under the laws of ……………., located in ……………, Local company name and address
Tel no: ………………………………………. Fax no:…………………………….…………. E-mail address: ……………………………...
Field trial protocol number ……………………... Release date: …………………………………….
…………………..…………………………………………..(name and address of person resident in Uganda) is authorized to represent us in Uganda for the application of a field trial certificate and to conduct the field trial and will be responsible for all matters pertaining to the field trial.
……………………………………… (Authorized Name and Signature) For: The holder of patent, licensed person or the manufacturer
FORM 41 Regulation 5(5)(d)
DECLARATION BY INVESTIGATOR
Field trial protocol number …………………………… Name: ………………………………………………… (Attach curriculum vitae).
I am aware of the responsibilities of my role as investigator in field trial number ……………………… as required by the laws of Uganda.
I have read and understand the attached field trial protocol, investigators brochure and supporting documentation and I will comply with the procedures and requirements included in them.
I have read the attached information as submitted to the Authority and confirm that the information is complete, true and accurate, and conforms to the field trial protocol and supporting documentation.
I will not commence with the field trial before written authorization has been received from the Authority. I will provide the Authority and other relevant bodies with the information as required.
I will obtain the consent of all the owners of the animals to be used in the field trial. I will ensure that every animal in the field trial is treated ethically. I will ensure that a veterinary doctor is involved in the field trial.
I DECLARE: I have no conflict of interest in terms of financial interests or personal relationships that may inappropriately influence my responsibilities and conduct of this field trial.
I DECLARE: I have not previously been associated with any field trial that has been terminated, or a field trial site that was closed, due to failure to comply with relevant laws for the conduct of field trials.
SIGNED ………………………………………… Date …………………….
WITNESS:…………………Signature………………..Date…………………
ECTOPARASITICIDE FIELD TRIAL CERTIFICATE
Ectoparasiticide field trial certificate number ……………………………….. issued under section
40
of the Act by the Authority.
Name of sponsor..……………………………………………………………… Physical address………….Telephone number ……………Fax number……… E-mail address ……………….…………………………………………………. Title of field trial protocol: …………………………………………………………… Number of field trial protocol:………………………………………………… Date of approval:……………………………Date of expiry:………………… Name and address of principal investigator…………………………………… Investigational product…………………………………………………………. Field trial site ………………………………………………………………….
The conditions of this field trial certificate - _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
…………………………… ……..………………… Executive Secretary Date
Form 43 Regulation 11 (2)
APPLICATION FOR DEVIATION FROM FIELD TRIAL CERTIFICATE
Title of the field trial:
Number of the field trial protocol: