Renewal of registration of an ACVM trade name product
ACVM 1R (August2014)

  • This form is to be completed by the Applicant/Registrant or their nominated New Zealand Agent/Consultant.
  • Registration (section 21) of a non-exempt ACVM trade name product is required to avoid committing an offence (section 8) under the Agricultural Compounds and Veterinary Medicines (ACVM) Act 1997.
  • Under section 10 of the ACVM Act, you must fill out this form as part of your product registration renewal.
  • Send this completed form and all required supporting documentationelectronically to
  • Refer to the Privacy Act 1993 and Official Information Act 1982 notices at the end of this form regarding collection of information by the Ministry for Primary Industries.

  1. Trade Name of Product
/ Reg Number
  1. Registrant Name

  1. Documentation

Currently marketed label (required)
Complete PDS (required)
Are there any changes? (delete one) NO YES NOTE: changes may require a variation application.
If YES, list here
NOTE: If your product registration lapsed 3 or more years ago, you may be required to provide further technical data and/or re-register your product. In this case, we will advise you.
  1. Applicant Statement

I confirm that:
  • I am authorised to make this application as the applicant/registrant OR a person with legal authority to act on behalf of the applicant/registrant noted in section 2; and
  • the information supplied in and with this application is truthful and accurate to the best of my knowledge; and
  • I understand that, if this product is registered, any change to the information provided in this application must go through the ACVM Group’s ‘variation to registration’ process or I will be in breach of the product’s registration conditions.

Name / Tel
Signature / Email
Date
  1. MPI Service Charge

ON PAYMENT THIS BECOMES A TAX INVOICE GST No: 64-558-838
APPLICATION FEE: Refer to schedule of fees on website.
PAYMENT OPTIONS:
Payments comprising multiple fees must be supported by a remittance advice. Please attach your advice to this application or send it separately to: MPI Approvals, PO Box 2526, Wellington 6140.
MPI does not accept cash. Payment must be made using one of the following methods. (Please fill in the appropriate section.)
APPROVED CREDITOR
DIRECT CREDIT:
  1. Pay into Bank Account no. 03 0049 0001709 002
  2. In the ‘Reference’ details, put the code: REGRENEW
  3. Enter the date of deposit and the payee name on this form below:
Date of Deposit / Payee Name
CHEQUE:
  1. Make the cheque payable to Ministry for Primary Industries.
  2. Attach the cheque to this application.

CREDIT CARD:
  1. Type of card you wish to use: (delete one) VISAMasterCard
  2. Fill in the card details below:
Card No:
Name on Card / Expiry Date
Signature
Collection of Information
Collection of Personal Information
Pursuant to Principle 3 of the Privacy Act 1993, we advise that:
  • This information is being collected for the purpose of registering a trade name product under the ACVM Act; and
  • The recipient of this information, which is the agency that will collect and hold the information, is the Ministry for Primary Industries, PO Box 2526, Wellington 6140; and
  • Some of the information being collected will be displayed on a public register; and
  • The collection of information is authorised under section 10 of the ACVM Act; and
  • The provision of this information is necessary in order to process this application for registration; and
  • The supply of this information is voluntary; and
  • Failure to provide the requested information is likely to result in a return of the application form to the applicant, and in accordance with the ACVM Act, may ultimately result in a refusal to register the product; and
  • Under Principles 6 and 7 of the Privacy Act 1993, you have the right of access to, and correction of, any personal information which you have provided.
Collection of Official Information
All information provided to the Ministry for Primary Industries is official information and may be subject to a request made under the Official Information Act 1982. If a request is made under that Act for information you have provided in this declaration, the Ministry for Primary Industries will consider any such request, taking into account its obligations under the Official Information Act 1982 and any other applicable legislation.

AC-APF-1R/August 20141