Processed by: the Department of Health
For use in: Chinese/western medicine
(medication, raw materials) medical instruments,
cosmetics, tissue/organs
APPLICATION FOR IMPORT CERTIFICATE
Page 1: Investigation report / Total Page(s) / Page no.Applicant / Country of origin
Unified code
(for personal application case please fill in your ID number) / Shipping port
Address and Tel. No. / Selling Country
Item / Description of Commodities Spec. and Brand or Maker, etc. / C.C.C.Code / Q’ty / Unit
Remarks
□ personal use：(1)copy of ID card(2)Copy of international package claim slip or customs bill(3)Outer box and manual of product (4)document of Medical diagnostic proof and prescription ( other than general medicines, oral vitamins, and cosmetics)
□ Inspection and registration：□ Medicine and medical instruments：(1)copy of authorization for medication (2)outer box and manual (instructions)or catalog of product (3) test delivery slip
□ Cosmetics：(1)Copy of business for profit registration (2)copy of international package claims slip or customs bill (3)outer box and manual of (instructions) or catalog of product
□ Clinical test medication(1)Country of manufacture、name of factory(2)name of instruments, serial number, amount(3)Express the procedure, use, and reason (4)copy of authorization for use of medication(5)letter of acknowledgement from Medical association or education institution (6)Instructions for the product (7)Letter of acknowledgement for devices which create ionized radiation (8)affidavit
□ Low volume hospital import(1)plan synopsis for treatment(2)authorization by committee for human experiments (3)authorization by patient (4) proof of placement on market or other information proving placement on market (5) Instructions (manual) or catalog of the product (6)Explanation why this product is unable to be replaced by a product already on the market
□ Self used raw material：(1)copy of authorization for manufacture (auth.no. ) (2)specifications, methods, test results of raw material tests (include batch number, test date, and signature of authorizing person).
□ imported organ or tissue(for transplant)：please attach documents for proof of safety
□ imported organ or tissue(for research)：please attach documents for proof of safety
□ government imported preventative vaccination / Certificate No.
Issue Date
Expiration Date
Signature of Applicant
Document no.
Date received
The CCC Code for this document is to be designated by customs.
Processed by: the Department of Health
For use in: Chinese/western medicine
(medication, raw materials) medical instruments,
cosmetics, tissue/organs
IMPORT CERTIFICATE
Page 2: Applicant declaration / Total pages / Page no.Applicant / Country of origin
Unified code
(for personal application case please fill in your ID number) / Shipping port
Address and Tel. No. / Country of seller
Item / Description of Commodities Spec. and Brand or Maker, etc. / C.C.C.Code / Q’ty / Unit
Remarks
□ Personally responsible for product effects and safety
□ Product can not be sold
□ Product can not be used clinically
□ Product limited to single packaging
□ Authorized for partial import
□ Use when other types are authorized
□ This authorization is limited for one use
□ This authorization is for multiple use
□ After import, the complete test of this batch of products will be inspected within 3 months. Those who do not comply within the limit are not authorized to apply again with later test results. / Certificate No.
Issue Date
Expiration Date
Approving Agency Signature
Document no.
Date received
The CCC Code for this document is to be designated by customs.
Processed by: the Department of Health
For use in: Chinese/western medicine
(medication, raw materials) medical instruments,
cosmetics, tissue/organs
IMPORT CERTIFICATE
Page 3: information / Total pages / Page no.Applicant / Country of origin
Unified code
(for personal application case please fill in your ID number) / Shipping port
Address and Tel. No. / Selling Country
Item / Description of Commodities Spec. and Brand or Maker, etc. / C.C.C.Code / Qty / Unit
Remarks
□ Personally responsible for product effects and safety
□ Product can not be sold
□ Product can not be used clinically
□ Product limited to single packaging
□ Authorized for partial import
□ Use when other types are authorized
□ This authorization is limited for one use
□ This authorization is for multiple use
□ After import, the complete test of this batch of products will be inspected within 3 months. Those who do not comply within the limit are not authorized to apply again with later test results. / Certificate No.
Issue Date
Expiration Date
Approving Agency Signature
Document no.
Date received
The CCC Code for this document is to be designated by customs.
Total pages / Page no.
⑦Item / ⑧Description of Commodities Spec. and Brand or Maker, etc. / ⑨C.C.C. Code / ⑩Q’ty / ⑪Unit
Certificate No. / Document no.
Date received
Continued Page for Import Certificate
Total pages / Page no.
⑦Item / ⑧Description of Commodities Spec. and Brand or Maker, etc. / ⑨C.C.C. Code / ⑩Q’ty / ⑪Unit
Certificate No. / Document No.
Date Received
Back Page
Certificate No.
Sale Authorization Product Log
Batch no. / Report form No. / Product item number, name, and amount / Total price / Customs Signature