Poisons licence application
Schedule 2 retail
Poisons Regulation 7
Poisons Act 1964
For enquiries or assistance with completing this form, please contact the Pharmaceutical Services
Branch on 9222 6883 or email [email protected].
Applicants please note:
1.
Only fit and proper persons may be issued with a licence to sell 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.
4.
Schedule 2 retail licences will not be issued within 25km of an operating pharmacy.
5.
Existing Schedule 2 retail licences will be revoked if a pharmacy opens within 25kms.
1. Applicant
Title:
Surname:
Company:
Premises address:
Premises suburb:
Telephone:
Email:
Postal address the same as above?
Postal address:
Postal suburb:
Forename/s:
Postcode:
Fax:
Yes
No
Postcode:
2. Storage
Where will the medicines be stored?
Behind the counter
Locked cupboard - may be glass fronted
Other, please specify:
Do you sell food and/or beverages?
Yes
No
If you sell food/beverages, you must store poisons in a manner that ensures food and
beverages will not be contaminated. Please check the following box to confirm
appropriate storage will be implemented.
3. Location
Distance from nearest pharmacy:
4. Involvement
Will you be working at the store?
kms
Yes
No
Poisons licence application Schedule
2 retail
page 2 of 2
5. 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: $126, 3 years: $189
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 :
$126
Card number:
Expiry date:
Signature of cardholder:
Date:
Direct debit to bank
Bank: Commonwealth Bank
BSB: 066 040 Account number: 13300018
Amount:
$126
$189
Receipt Number:
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
$189