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Warning Text %XTableStyleMedium2PivotStyleLight1683ffffյ3f3fff3f3f33333fI}3333f3f33333f33333\`xSEPA 2024 TAB 1 SEPA 2024 TAB 25 iTAB 17Name of Applicant (as it appear on MCC/SAHPRA License):*Trade Name of Applicant (i.e. trading as):Name of Contact Person:*Email address of the contact person above:NTelephone number, cellphone number and fax number of the contact person above "THIS COLUMN IS FOR OFFICE USE ONLYApplicant MCC/SAHPRA Licence No,Applicant Name as Registered with MCC/SAHPRA#MCC/SAHPRA Medicine Registration No Nappi CodeATC 4 Code (WHO)ScheduleMedicine Proprietary NameActive IngredientsStrengthUnit Dosage Form Pack SizeQuantityManufacturer Price Logistics FeeVATSEP Unit PriceEffective DateStatusOriginator or GenericRequested Manufacturer PriceRequested Logistics FeeVAT on Request Requested SEPRequested Unit Pricenumerical field2 decimal placesno currency symbols right indent right indent TAB 2&For the purposes of Regulation 8 (1) d AUSTRALIACANADA NEW ZEALANDSPAINALTERNATIVE COUNTRY 1ALTERNATIVE COUNTRY 2& & .etc Applicants MCC/SAHPRA Licence No"Product MCC/SAHPRA Registration NoATC 4 Product Proprietary NameClosest Aus pack sizeRelated Aus QtyAus Man Price Aus$AUS$ Exchange RateAUS Price in Rands,AUS matching pack price in Rands (Excl VAT) $Comment on Australian Price ProvidedClosest Canada pack sizeRelated CAN QtyCAN Man Price Can$CAN$ Exchange RateCAN Price in Rands,CAN matching pack price in Rands (Excl VAT) "Comment on Canadian Price ProvidedClosest NZ pack sizeRelated NZ QtyNZ Man Price NZ$NZ$ Exchange RateNZ Price in Rands+NZ matching pack price in Rands (Excl VAT) %Comment on New Zealand Price ProvidedClosest Spain pack sizeRelated Spain QtySpain Man Price EuroEuro Exchange RateSpanish Price in Rands.Spain matching pack price in Rands (Excl VAT) !Comment on Spanish Price ProvidedClosest Alt Country pack sizeRelated Alt Country QtyMan Price Alternative Currency"Alternative Currency Exchange Rate"Alternative Country Price in Rands<Alternative country matching pack price in Rands (Excl VAT) -Comment on Alternative Country Price ProvidedFIS OR WAS THERE A PATIENT ACCESS PROGRAMME FOR THIS MEDICINE (YES/NO)MHOW MANY PATIENTS ARE OR WERE ON A PATIENT ACCESS PROGRAMME FOR THIS MEDICINEExampleOnly for description of processThe Example in New Zealand is packed in boxes of 60 that are shrink wrapped in 3's. The price in the "NZ matching pack price in Rands" column is the equivalent New Zealand price in Rands for the pack and quantity represented here on this row for South Africa. NOTE:<1. NO amended version of this template will be acceptable. k3. The exchange rates for Australia, Canada, New Zealand and Spain are already provided in this template. 14. The formating for this template is as per DoP AUSCANNZDEUR+2024 SINGLE EXIT PRICE ADJUSTMENT TEMPLATEGREQUESTED 2024 SEP ADJUSTMENT (Reductions are allowable in this column)SEP ON 20 DECEMBER 2023+Volume of Sales (01Jan 2022 to 31 Dec 2023)  2024 SEPA TEMPLATE +Volume of Sales (01Jan 2022 to 31 Dec 2023) s2. 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