Microsoft word - form6 application form complete.doc

Poisons Act 1971
Section 27
Poisons Regulation 2002
62(2)(a)
APPLICATION FOR A LICENCE TO SELL OR SUPPLY CERTAIN SUBSTANCES
To the Minister for Health and Health Services I, . (name, address and nature of business) hereby apply for a licence/renewal of licence to sell or supply the following substances to which Section 27 of the
Poisons Act 1971 applies:
SCHEDULE 2 SUBSTANCES EXCEPT THE FOLLOWING: -

As attached in Appendix 1
I declare that: -
I am thoroughly conversant with the provisions of the Poisons Act 1971 and Poisons Regulations 2002 in relation to the supply of the licenced substances. I have a thorough understanding and command of the English language. I am the person who will be responsible for the safe custody of such substances and for due observance of the provisions of the Poisons Act and Regulations.. attach/I
previously
attached
magistrate/mayor/warden certifying that I am a fit and proper person to sell the substances for which I have applied. My business will be carried on only at the above premises which are situated at least 10 kilometres by the nearest practicable route from a place in which a pharmaceutical chemist keeps an open shop. The statements made in this application are true and correct. Application fee $32.00 Please pay on enclosed invoice and forward a copy of the receipt with your application to the
address below.
PHARMACEUTICAL SERVICES BRANCH
DEPARTMENT OF HEALTH AND HUMAN SERVICES
GPO BOX 125
HOBART TAS 7001
ABN 11255872006
New applications must be forwarded with supporting documents to the address above and an invoice will be forwarded once the application is approved.
Appendix 1:

SCHEDULE 2 SUBSTANCES EXCEPT THE FOLLOWING: -
a) unscheduled aspirin products; or b) when in combination with Schedule 2 codeine in solid dosage form products for the treatment of pain 2. Products containing DICYCLOMINE for infants. a) unscheduled ibuprofen products; b) in ibuprofen liquid products containing no other therapeutically active substances in packs of 100ml or less for the treatment of pain in children; c) in Schedule 2 liquid preparations for the treatment of colds, cough and influenza;or d) when in combination with Schedule 2 codeine in solid dosage form products for the treatment of pain a) Unscheduled paracetamol products; b) in paracetamol liquid products containing no other therapeutically active substances in packs of 100ml or less for the treatment of pain in children; c) in Schedule 2 liquid preparations for the treatment of colds, cough and influenza;or d) when in combination with Schedule 2 codeine in solid dosage form products for the treatment of pain 6. Products containing PHENIRAMINE for travel sickness.

Source: http://ablis.geometryit.com/resource/TAS/State/AP6054.pdf