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Proof of Payment Notes 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 http //www. mhra*gov*uk/fees 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 http //www. mhra*gov*uk/fees/faqs Declaration 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 Cheque Append a scanned copy of the cheque to the form and send the original cheque to Cashiers MHRA Finance Market Towers 1 Nine Elms Lane LONDON SW8 5NQ Include a cover letter with the original cheque with the following information Company Name BACS Transfer Please provide the following information Remitters Name Remitters Account Number Sort Code Date of Transfer Amount CHAPS Transfer Credit Card Payment MHRA Transaction ID No Fee Liability The submission type does not incur a fee. pdf* For latest MHRA Fees see http //www. mhra*gov*uk/fees 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 http //www. 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 http //www. mhra*gov*uk/fees/faqs Declaration 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. mhra*gov*uk/fees/faqs Declaration 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 Cheque Append a scanned copy of the cheque to the form and send the original cheque to Cashiers MHRA Finance Market Towers 1 Nine Elms Lane LONDON SW8 5NQ Include a cover letter with the original cheque with the following information Company Name BACS Transfer Please provide the following information Remitters Name Remitters Account Number Sort Code Date of Transfer Amount CHAPS Transfer Credit Card Payment MHRA Transaction ID No Fee Liability The submission type does not incur a fee.

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