English — reviewed original text

APPLICATION FORM FOR LICENSING OF PREMISES PBSL-F-75/22 THE PHARMACY AND DRUGS ACT 2001 SECTIONS 19/20/38/45 TO:………………………………………………………………………… (Import/Export/manufacturer/Distribute/wholesale/Retail) Class A, B, C Drugs and Medical Devices…………………………………………… Class B and C Drugs and Medical Devices :………………………………………… Chemical Reagents………………………………………………………………… Class C Drugs……………………………………………………………………… Nutritional Agents………………………………………………………………… Cosmetics…………………………………………………………………………… (Please tick where applicable) Name of Pharmaceutical Business/Enterprise:……………………………………… Address……………………………………………………………………………… Location of Premise: District……………………Province………………………… Chiefdom……………………Constituency…………Ward………………………… City……………………Town……………………Village………………………… Tel:……………………E-mail……………………Fax:…………………………… Proposed Business Hours Monday-Friday | Saturday | Sunday | | Name of Proprietor………………………………………………………………… Proprietor’s qualification (Profession/Education)…………………………………… Contact Address:…………………………………………………………………… Tel:……………………E-mail:…………………………………………………… Date:……………………Signature of Proprietor:………………………………… Page 1 of 2

APPLICATION FORM FOR LICENSING OF PREMISES PBSL-F-75/22 Name of fulltime Pharmacist/Superintendent Pharmacist/Pharmacy Technician ……………………………………………………………………………………… Registration No (s):………………………………………………………………… Home Address…………………………………………City……………………… Tel:……………………E-mail……………………………………………………… Dated:……………………Day of……………………20…………………………… DECLARATION TO BE COMPLETED BY PHARMACIST/PHARMACY TECHNICIAN-IN-CHARGE I hereby certify that all the above information is correct to the best of my knowledge and hereby accept to be the Pharmacist/Pharmacy Technician-in-charge of the above mentioned business entity and by so doing accept all legal responsibility pertaining to the said business. Sig. Pharmacist-in-Charge:…………………… Date:……………………Reg. No……… Sig. Pharm Tech-in-Charge:…………………… Date:……………………Reg. No……… DECLARATION TO BE COMPLETED BY THE PROPRIETOR I……………………hereby certify that all the above information is correct to the best of my knowledge and hereby agree to comply with the provisions of the Pharmacy and Drugs Act, 2001. Sign:…………………… Date:…………………… Page 2 of 2