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 will never be able to use human or pork insulins 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