1964_PHARMACY_AND_POISONS_REGULATIONS — Page 74

CAP. 138]

Pharmacy and Poisons Regulations

FORM 11

[Spent]

FORM 12

[reg. 36B(3).]

表格十二

〔規例第三六乙條第(三)款〕

PHARMACY AND POISONS ORDINANCE

(Chapter 138)

藥劑及毒藥條例

(香港法例第一三八章)

CERTIFICATE FOR CLINICAL TRIAL/MEDICINAL TEST* 臨症試驗/藥物試驗證明書

It is hereby certified that

茲證明

(Name and address)

(名稱及地址)

is authorized to establish a clinical trial on human beings/medicinal test on animals* in respect of

已獲授權將下述製品或物質以人類為對象進行臨症試驗/以動物為對象進行藥物試驗*

(Name of product or substance)

(製品或物質名稱)

to be conducted by

上項試驗之主持人為

(Name(s) of person(s) concerned)

(有關人士之姓名)

at

(Name and address of institution where applicable)

試驗地點

(如適用，填寫機構名稱及地址)

2.

This certificate will be valid until

本證明書有效期至

(Date)

日期：

止。

。

HONG KONG

香港

藥劑業及毒藥管理局

for Pharmacy and Poisons Board.

代行