Certification for Personal
Use
(one of 4 FDA required
documents)
I,
______________________________________,
(Your Name)
SS#
______-____-________, residing at
(Your Social Sec. #)
(Your
address)
do hereby certify that the
types and amounts of insulin, ordered
this shipment, are for
personal use only for me and are about
the correct amounts to last me for a
period of less than 6 (six) months.
I further certify
that while the amounts and types of
insulin that I may require may vary
widely from day to day and month to
month that there is no commercial or
resale intent in my orders from CP
Pharmaceuticals.
I am not able
to use any of the insulins or insulin analogs available in
the United States and
respectfully request that the FDA, USDA
and US Customs recognize this fact of my
diabetic life and grant a permanent
authority for me to buy the drugs I need
to stay alive rather than jeopardize my
health and very survival with reviews,
delays and fees and charges and risk of
loss on each and every shipment.
Certified this ____
Day of ____________, 20___.
(Your Signature)
USDA
Import Permit,
Doctor’s
Certificate of Medical Necessity,
and Personal
Certificate of personal use and 6 month
supply
|