Poisons licence application
Schedule 7 retail
Poisons Regulation 8
Poisons Act 1964
For enquiries or assistance with completing this form, please contact the Medicines and Poisons
Regulation Branch on 9222 6883 or email [email protected]
Applicants please note:
1.
Applicants must have a relevant qualification or be able to demonstrate at least five years
experience working with the poisons in the application or similar poisons.
2.
Penalties apply for providing false or misleading information in this application under
Section 35 of the Poisons Act 1964.
3.
It is the responsibility of the Licence holder to ensure compliance with the Act and Poisons
Regulations 1965, and compliance with conditions placed on the licence.
1. Applicant
Company:
Title:
Surname:
Postal address:
Postal suburb:
Telephone:
Email:
2. Premises
Premises address same as postal?
Premises address:
Premises suburb:
Telephone:
Forename/s:
Postcode:
Fax:
Yes
No
Postcode:
AgSafe premises accreditation number:
Expiry:
Premises purpose as approved by Local Government:
Please note: Local Government will be asked to comment on all applications. This may increase
processing time.
3. Poisons required
Please list all of the Schedule 7 poisons you wish to sell:
Name of poison
Approximate quantity kept on hand
Poisons licence application Schedule
7 retail
page 2 of 4
4. Qualifications and experience
Applicant has:
Relevant
≥5 years experience working with these or
qualification
similar poisons
Qualification:
Name of institution:
Name of qualification:
Year of completion:
Evidence of qualification attached
Experience:
Curriculum Vitae attached OR
Detail below ≥5 years relevant experience working with these/similar poisons
Position held
Company name
Years
Experience
AgSafe personnel accreditation number:
or AgSafe AgVet Chemical Supplier course completed (date):
Expiry:
Please note: AgSafe training alone is insufficient for the issue of a Schedule 7 Retail licence. Applicants must
have a relevant qualification or demonstrate sufficient experience working with poisons.
5. Storage and security
Schedule 7 poisons stored inside are stored:
Locked cupboard
Locked caged area
Behind counter
Other, please specify:
Schedule 7 poisons stored outside are stored:
Locked shed
Locked caged area in shed
Other, please specify:
Poisons stored outside are stored under cover?
Yes
No
Large quantity schedule 7 storage areas are bunded?
Yes
No
Liquid spills will drain to a holding pit, tank or sump?
Yes
No
Does the site require a Dangerous Goods (DG) Site Licence*?
Yes
No
If yes, please attached a copy of the DG Site Licence.
*see Department of Mines and Petroleum website
Security – please tick all that apply:
Perimeter alarm
Perimeter fence
Monitored alarm system
CCTV
Motion detectors
Other, please specify:
Please attach a mud map of the premises, including any outside storage area showing where
schedule 7 poisons will be stored, security measures and the location of perimeter fencing gates.
Poisons licence application Schedule
7 retail
6. Safety and emergency equipment
Is a safety shower available?
Are eyewash facilities available?
Is a first aid kit kept on site?
Is personal protective equipment (PPE) available (particularly for spill clean-up)?
Does the site have spill clean-up equipment?
Does the site have an on-site emergency plan?
page 3 of 4
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
7. Record keeping
Records of Schedule 7 sales are kept:
in a hard copy register
on computer
Computer records: customers must sign for the receipt of Schedule 7 poisons. How do you match
customer signatures with the rest of the sales record?
Register/computer record contains:
Name and address of purchaser
Date of sale
Name, strength and quantity of product supplied
Premises at which the poison is intended to be used
Signature of the purchaser
How many years will sales records be kept?
8. Strychnine and 1080 (fluoroacetate)
Only complete this section if you are applying for a licence for 1080 or strychnine.
I confirm I have read, understood and agree to comply with:
Code of Practice for the safe use and management of 1080 in Western Australia
Code of practice for the safe use and management of strychnine in Western Australia
9. Section 24 Notice
I confirm I have read, understood and agree to comply with:
Poisons Section 24 Notice 2005, pages 917-928 (490KB)
Poisons licence application Schedule
7 retail
page 4 of 4
10. Declaration
I,
provide full name
of:
provide full address
hereby declare:
i.
I am over 21 years of age.
ii.
The information contained in this application form to be true and correct.
iii.
I am aware that penalties apply under section 35 of the Poisons Act 1964 for providing false
or misleading information in this application.
iv.
I am familiar with the provisions of the Poisons Act 1964 and Poisons Regulations 1965
relevant to the poisons to which this application relates.
v.
As licence holder I am aware of my responsibility for the safe storage and use of poisons
and will ensure compliance with the Poisons Act 1964 and Poisons Regulations 1965, and
compliance with conditions placed on the licence.
vi.
I will notify the Department of Health if details on this form change including:
if the licence holder leaves employment or takes extended leave
if there is a change of premises or storage address
when additional poisons are required
Signature of applicant:
Date:
Payment options
Application fee:
1 year: $228, 3 years: $369
Cheque or money order – made payable to: DEPARTMENT OF HEALTH
Credit card - American Express and Diners not accepted
Card type:
Mastercard
Visa
Name on card:
Amount :
Card number:
Expiry date:
Signature of cardholder:
Date:
Direct debit to bank
Bank: Commonwealth Bank
BSB: 066 040
Amount:
$228
$369
Receipt Number:
Account number: 13300018
Payment date:
Submission
Please post completed form to:
Health Corporate Network
PO Box 8549
PERTH BUSINESS CENTRE WA 6849
Payment enquiries: 1300 367 132
2015 Updated July 2016
$228
$369