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:

− PLPI number
− Company Name

1
BACS Transfer
Please provide the following information:
Remitters Name:
Remitters Account Number:
Sort Code:
Date of Transfer:
Amount:

CHAPS Transfer
Append a scanned copy of the CHAPS Advice Details to the form.

Credit Card Payment

MHRA Transaction ID:

No Fee Liability
The submission type does not incur a fee.

For and on behalf of (Company Name):

Name:

Position:

Date:

Email:

Tel: