Proof of Payment Form - DOC by 28roD35Y


									Proof of Payment Form

                                         Proof of Payment


This Proof of Payment form should be completed and saved as a PDF document. It
must be included with the application. If a completed form is not included, the
application will be rejected and the applicant will be required to resubmit the entire
application. For submissions in Special MAIL 5 format (Market Authorisation or PLPI
submissions), the form should be named m1-2-5-1-proof-of-payment.pdf.

For latest MHRA Fees see

In connection with a major application for a Market Authorisation from a small
company, there is provision in the fee regulations for some payment easements.
Applications for this provision must be made in writing. For application details of this
scheme, including payment schedules and the definition of small company, see Fees
– Frequently Asked Questions at


         I confirm that the fee for the following application has been paid in full.

         PLPI number*:
         Type of submission:
         Fee Amount:

*If this submission is a collection, please state the lead PLPI number only.

  Tick method of payment and provide details if applicable

         Append a scanned copy of the cheque to the form and send the original
         cheque to:

         MHRA Finance
         151 Buckingham Palace Road
         SW1W 9SZ

         Include a cover letter with the original cheque with the following information:

            PLPI number
            Company Name
BACS Transfer
Please provide the following information:

Remitters Name:
Remitters Account Number:
Sort Code:
Date of Transfer:

CHAPS Transfer
Append a scanned copy of the CHAPS Advice Details to the form.

No Fee Liability
The submission type does not incur a fee.

For and on behalf of (insert company name):




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