This certificate is issued by me, the undersigned, for the purpose of section 69 of the Pharmacy Act 2007, being—

1................................................................

I hereby certify that I received, on the day of

, from 2.

..

of

a sample of the relevant thing/the relevant thing*,

being 3.

for test, examination or analysis; which

was undamaged, duly sealed and marked 4..

.

I further certify that the said sample/relevant thing has been tested, examined or analysed by me or under my direction and that the results are as follows— 5..

.

.

Signature

Date

Address.

.

.

1. Here insert official title of person signing the certificate.

2. Here insert the name of the authorised officer who submitted the sample of the relevant thing, or the relevant thing, as the case may be.

3. Here insert the name or description of the relevant thing.

4. Here insert distinguishing mark on the sample of the relevant thing, or the relevant thing, as the case may be, and the date shown on its container as the date of sampling, or the date on which the relevant thing was taken into possession, as the case may be.

5. Here insert the relevant results as appropriate.

* Delete whichever is inapplicable.