MCA-F-412/01, Version 1 — Application for Licensing of Storage Facilities for Medicines and Related Products
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Contents
MEDICINES CONTROL AGENCY
MCA
THE GAMBIA
MEDICINES CONTROL AGENCY
Kairaba Avenue, K.S.M.D. Pipeline, The Gambia. Telephone: (+220)4380632, www.mca.gm
APPLICATION FOR LICENSING OF STORAGE FACILITIES FOR
MEDICINES AND RELATED PRODUCTS
New licence ☐ Renewal ☐ Licence No.
PARTICULARS OF APPLICANT
Name of Applicant
Name of Facility
Type of Facility Private ☐ NGO ☐ Government ☐
Location (Physical
Address)
Contact Details
Telephone No.
Email
Website
Name of Business Owner
Name of Officer in Charge (if applicable)
Name of Supervising Pharmacist (if applicable)
Registration No:
FOR NEW LICENCES ONLY
Date of Incorporation of Company
Business Registration number
MCA-F-412/01, Version 1 – 10 July 2020 Page 1 of 2
Original PDF page 1 — retained source fields, tables and layout.
Application for Licensing of Storage Facilities for
Medicines and Related Products MCA The Gambia
ITEMS TO BE STORED (Tick all as appropriate)
For Human use ☐ For Veterinary use ☐
Medicines
Allopathic ☐ Herbal ☐ Homeopathic ☐ Biological ☐
Nutritional Supplement ☐
Other products
Cosmetics ☐ Medical Device ☐ Diagnostics ☐
Other ☐ (please specify)
Attach the required documents
DECLARATION
I, the undersigned, hereby declare that all information Official Stamp
contained herein is correct and true.
Designation of Business Owner or Officer in Charge:
Signature:
Date:
MCA-F-412/01, Version 1 - 10 July 2020 Page 2 of 2
Original PDF page 2 — retained source fields, tables and layout.
