Form :QA-11 Effective Date :01.01.

15

Leon Pharmaceuticals Limited

Sample Collection Form

Serial number: .

Name of location/place where sample was taken:

..............................................................................................................................
..............................................................................................................................
Address (with telephone and fax number, if applicable):
..............................................................................................................................
..............................................................................................................................
Date of sampling: ...............................................................................................
Names of people who took samples:
1. .........................................................................................................................
2. .........................................................................................................................

Product name of the sample: ............................................................................

Name of (active) starting material (INN, generic or scientific name)
with dosage strength: .........................................................................................

Dosage form (tablet, capsule, etc.): .................................................................

Batch/lot number: ..............................................................................................
Date of manufacture: ........................... Expiry date: ............................
Registration or licence number (if applicable): .............................................
Name of the manufacturer: ..............................................................................
Number of sample unit taken (tablet, capsule, etc.: at least 20 but not more
than 30 units):
..................................................................................................................

Brief physical/visual description of sample:

..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
Signature of person(s) taking
1. .............................................
2. .............................................