Advisory Committee On Borderline Substances Certificate Request Form : MHRA

Please use this form to request the certificate required in respect of products being submitted to the Advisory Committee on Borderline Substances (ACBS). For further information see the ACBS section.

Important notice:
Please ensure that you finalise all decisions for your product(s) before submitting the information to MHRA. The information on this form and the copies of the packaging that you provide for MHRA must be identical to that which you provide for ACBS.

A copy of our letter and all the material you submit to the MHRA will be sent to ACBS for their information. If there are differences, the MHRA certificate is invalidated. If any discrepancies are found, the ACBS will advise the MHRA and we may then require a complete re-submission to confirm the original certification. In such cases we cannot guarantee the certificate will be issued to meet the ACBS deadline.

Fields indicated with a * are mandatory.

Company details Company name*
Company Address*
Postcode*
Company’s reference number (if any)

Contact details Title*
Contact name*
Correspondence address*
Postcode*
Telephone number
Email address*
Confirm email address*

Product Name/Submission Type Note: Opinion will only be based on the information provided
Product name*
Is this a Type 3 submission (Existing products to which minor changes are proposed)? YES / NO*
If this is a Type 3 Submission please specify the change to the current product

Food for a Specific Medical Purpose (FSMP) Note: If your product is presented as a food for special medical purposes you must notify the Food Standards Agency. Please contact: Derek.Hampson@dh.gsi.gov.uk for further advice.
Is your product a Food For a Special Medical Purpose (FSMP)?*
Please state the specific disease, disorder or medical condition for which the product is intended*
Please state how this product will meet the particular nutritional requirement of persons affected by or malnourished because of the stated condition*

Product Details Product Form*
( e.g tablet, capsule, cream etc.)
Please include details of the amount of each ingredient. If the ingredient is herbal please give the botanical name and the part of the plant being used.
Ingredients:*
Dosage Instructions:*
Product's mode of action:

Purpose of product including claims / wording used to promote the product:*

Attach file(click the icon to browse for a file)
Note: All promotional material relating to the product must be attached

Note - Opinion will only be based on the information provided. ACBS will require additional information and documentation as set out in the information on the
Commercial Medicines Unit Website. (external link)

Advisory Committee on Borderline Substances Certificate Request Form