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                        Model Shipment Request/Notification Form
                    for Emergency Supplies of Controlled Substances

Operator:

Name:........................................................................................
Address:.....................................................................................
Name of the responsible medical director/pharmacist:.........................................
Title:.......................................................................................
Phone No..............................  Fax No...............................................

Requests the supplier(1):

Name:........................................................................................
Address:.....................................................................................
Responsible Pharmacist:......................................................................
Phone No..............................	Fax No...............................................


For an emergency shipment (2) of the following medicine(s) containing controlled
substances:

Name of product (in INN/generic name) and dosage form, amount of active ingredient
per unit dose, number of dosage units in words and figures


Narcotic drugs as defined in the 1961 Convention (e.g. morphine, pethidine, fentanyl)


[e.g. Morphine injection 1 ml ampoule; morphine sulfate corresponding to 10 mg of
morphine base per ml; two hundred (200) ampoules]
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................

Psychotropic substances as defined in the 1971 Convention [e.g. buprenorphine,
pentazocine, diazepam, phenobarbital]
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................

Others (nationally controlled in the exporting country, if applicable)
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................






To the following recipient (whichever applicable):

Country of Final recipient:..................................................................
Responsible person for receipt:
Name:........................................................................................
Organization/Agency:.........................................................................
Address:.....................................................................................
Phone No................................Fax No...............................................



For use by/delivery to:

Location:............................Organization/Agency:....................................
         ............................                    ....................................
                                                         ....................................

Consignee (If different from above e.g. transit in a third country):

Name:................................Organization/Agency:....................................
Address:.....................................................................................
Phone No................................Fax No...............................................

Nature of the emergency (Brief description of the emergency motivating the request):
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................

Availability of, and action taken to contact the control authorizes in the receiving
country:
.............................................................................................
.............................................................................................

I certify that the above information is true and correct. My Organization will:

- Take responsibility for receipt, storage, delivery to the recipient/end-user, or
use for emergency care(strike out what is not applicable) of the above controlled
medicines;

- Report the importation of the above controlled medicines as soon as possible to
the control authorities (if available) of the receiving country;

- Report the quantities of unused controlled medicines, if any, to the control
authorities of the receiving country (if available), or arrange for the end-user
to do so (strike out what is not applicable).


Title: .....................................  Date: .........................................

Location: .................................

                                              ...............................................
                                                             (signature)

1  If the operator is exporting directly from its emergency stock, it should be
   considered as a supplier.

2  Emergency deliveries do not affect the estimate of the recipient country since
   they have already been accounted for in the estimate of the exporting country.