Appendix 1
To Rules to import into
and export from the Russian Federation
biological materials obtained in
a clinical trial of a medicinal
product for medical use

Form

Coat of arms of the Russian Federation

MINISTRY OF HEALTHCARE AND SOCIAL DEVELOPMENT OF
THE RUSSIAN FEDERATION

Permit No. ___________

to import (export) biological materials obtained in a clinical trial of medicine _________________ of medical use

Issued to _________________________________________________________
(name of the petitioning organization to import (export) biological materials)

based on request of ____________________________ No.         ______________
(date)

to import (export) ________________________________________________________
(type of imported (exported) biological material)
________________________________________________________________,
(number of units of each type of imported(exported) biological material, type of packing for each type of imported (exported) biological material)

obtained in a clinical trial of medicine ________________ of medical use, as authorized by the Ministry of Healthcare and Social Development of the Russian Federation by permit of _____________________ No. _________
(date)

according to clinical trials report ____________________________
(title of report)

for ____________________________________________________________.
(objective to import (export) biological materials, name of the nation state, location and full name of organization to receive imported (exported) biological materials)

This Permit is valid until ______________________________________
(date)

___________________      ____________________      _____________________
(position)                               (signature)                                (full name)

"_____" _________________ 201_  stamp here