Health Act 1937
Health (Drugs and Poisons) Regulation 1996 /
Application for a Licence as a Wholesale Representative
(please refer to the Fact Sheet at the back of this form when completing this application) / Licence no: POI-P
Receipt no:
Client no:
1. Applicant details
Given names

(do not abbreviate)

/

Surname

Include maiden name if married)

The licence will be issued in the name recorded above
Date of birth / Birthplace / Town
Country
The licence certificate must be in the possession of the person to whom it is issued at all times. Please ensure that only your private residential and postal addresses are stated below. Do not use your employer’s addresses.
Residential address
Telephone / Mobile
Private postal address

(for all correspondence)

E-mail address / Fax
2. Storage premises for samples
Business name
(include name of building, if applicable)
Street address
(include shed/unit no)
Telephone (not mobile)
3. Payment of fees
Prescribed fee / $77.00 / Refunds: See Fact Sheet / Tick if receipt required
1 box only / Cheque or Money Order enclosed (payable to Queensland Health)
Payment by Credit Card (see last page)
Note:This is a GST free item. Queensland Health ABN 66 329 169 412
4. Disclosure
Have you:
  • been convicted of an indictable offence?
(Drink driving and minor traffic offences are not indictable offences) / Yes / No
  • been convicted of an offence against the Health Act 1937 or the Health (Drugs and Poisons) Regulation 1996 or a repealed provision or a corresponding law?
/ Yes / No
  • held an licence granted under the Health (Drugs and Poisons) Regulation 1996 or a repealed provision or a corresponding law that was suspended or cancelled?
/ Yes / No
  • ever been refused a licence under the Health (Drugs and Poisons) Regulation 1996 or a repealed provision or a corresponding law?
/ Yes / No
If YES, please attach documentation that provides details of the offence, the nature of the offence and the circumstances of its commission. Applicants are advised that in order to ensure the requirements of Section 15 of the Health (Drugs and Poisons) Regulation 1996 are met, Queensland Health may in certain circumstances, provide the information contained in this application to relevant external agencies.

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5. Declaration - Employee
I declare that the information stated by me on this application form is true, correct and complete / Yes / No
I consent to the making of enquiries of, and the exchange of information with the authorities of any State, Territory or Commonwealth regarding any matters relevant to this application. / Yes / No
I have read, understand and agree to comply with my obligations as required under the relevant provisions of the Health (Drugs and Poisons) Regulation 1996(see publication, What Wholesale Representatives Need to Know andthe respective legislation,available at ). / Yes / No
I apply for a Licence as a Wholesale Representative and enclose the prescribed fee identified at section 3. / Yes / No
Signature / Date
Print full name here
Employer Information
This section should be completed by a person who has authority from the Employer (other than the applicant).
6. Employer details
Employer name
Australian company number (if applicable)
Website(if applicable)
7. Business address
Business name
Street address
Postal address

(for all correspondence)

Contact person
Telephone (not mobile) / Fax
E-mail address
8. Poisons licence
  1. It is the employer’s responsibility to ensure that either –
(a) a current Queensland restricted drug manufacturer licence or restricted drug wholesaler licence is held; or
(b)a licence, issued under a law in another State, that is equivalent to a Queensland restricted drug manufacturer licence or restricted drug wholesaler licence is held.
  1. Queensland licensees

Licence number / W / Z *
* Delete whichever does not apply / Expiry Date
  1. Interstate Licensees 1 box only
  • Attach a certified photocopy of the current licence to manufacture and/or wholesale restricted drugs; or
  • The current interstate licence has previously been forwarded

9. Declaration - Employer
I declare that the information stated by me on this application form is true, correct and complete / Yes / No
I declare that the employer holds a current restricted drug manufacturer or restricted drug wholesaler licence or an equivalent interstate licence. / Yes / No
I consent to the making of enquiries of, and the exchange of information with the authorities of any State, Territory or Commonwealth regarding any matters relevant to this application. / Yes / No
I have read, understand and agree to comply with my obligations as required under the relevant provisions of the Health (Drugs and Poisons) Regulation 1996(see publication What Wholesale Representatives Need to Know and legislation website ). / Yes / No
I am authorised by the employer to make this declaration on behalf of the employer. / Yes / No
I enclose the prescribed fee identified at section 3. / Yes / No
Signature / Date
Please print full name here
Position in company
Credit card payments
  • Thispage should only be completed if payment is being made by Mastercard, Bankcard or Visa card.
  • American Express is NOT available
  • Please ensure that this page is returned with the application only if paying by this method. Do not return this page if payment is being made by cheque or money order.

Name of applicant
Prescribed fee
Amount at section 3 / $
1 box only / Mastercard
Bankcard
Visa card
Card no
Expiry date / /
Name on card
(Please print)
Signature
of cardholder / Date
Fact Sheet
Health Protection Unit /

Application Guide for a Licence as a Wholesale Representative

General information for employees and employers
  1. This information has been prepared to assist you in applying for a Licence as a Wholesale Representative. Following this advice will enable timely consideration of your application.
  2. When you complete the form, please print clearly and answer all sections in full.
  3. Applications are processed only when all the information requested is provided. You will be notified by mail if the licence is granted.
  4. All forms requiring a signature must bear the original signature in ink. Queensland Health is not able to accept a photocopy, facsimile (fax) or emailed copy of the completed form. Applications must be forwarded by POST to the address provided below.
  5. Each page of any photocopied official documents that are submitted in support of this application must bear the certification and original signature of an authorised Identifier ie. Justice of the Peace, Commissioner for Declarations or an officer from one of Queensland Health’s Public Health Units (PHU). PHU contact details are located at
  6. A representative must possess the original copy of his/her licence. For this reason, Queensland Health is not able to provide a copy of the licence to an employer for their records.
  7. Refunds - Queensland Health can only provide a refund if:

(a) the application is refused by the Chief Executive; or

(b) the application is withdrawn prior to a decision being made by the Chief Executive.

  1. Further information, as it applies to medicines and poisons, may be available from Queensland Health’s Drugs & Poisons Policy & Regulation website at

The completed application must be returned to –

Licensing Officer

Public Health Regulation & Licensing Team

PO Box 2368

FORTITUDE VALLEY BC Q 4006

(07) 3328 9310

Employee information
  1. An applicant must be employed as a wholesale representative by a licensed manufacturer or wholesaler of Schedule 4 restricted drugs for the purpose of displaying and/or supplying samples of those substances to doctors, dentists, veterinary surgeons and pharmacists only.
  1. A representative must not store, display or supply samples of Schedule 4 restricted drugs to doctors, dentists veterinary surgeons or pharmacists unless he/she is in possession of a current Licence as aWholesaleRepresentative issued by Queensland Health.
  1. A licence will contain conditions that refer to the quantities of drugs and poisons that the holder may possess.
  1. A Licence as aWholesale Representative is valid only while the representative continues to be employed by the employer nominated on this application. The licence is not transferable between employers. When a licence holder changes his/her employment, the licence becomes invalid and an application must be made for a new licence by the employee.

Do not return this fact sheet with the application

How to complete Employee sections of the application

Please each checkbox below as you complete the application form to ensure that you have provided the necessary particulars.

Section 1Applicant details

Providename as it appears on your birth certificate. If you have ever been known by any other name, attach any certified copies of documentation that provides for formal changes of name ie. deed poll, marriage certificate etc.

Section 2Storage premises for samples

Provide the name of the business (including name of building, if applicable) and full street address of the physical premises where samples are to be stored. Do not provide a post box address or a mobile telephone number.

Section 3Payment of fees

Payment of the prescribed fee is to be attached with the application.

Section 4Disclosure

If you have answered yesat any checkbox, attach copies of the following documents –

Certificate of conviction / court or tribunal order / police records search.

Australian Securities Investment Commission Order (ASIC) preventing an individual from managing a corporation.

Section 5Declaration

The form is signed and dated by applicant named at Section1.

Employer information

(The Employer or person who has authority from the Employer (other than the applicant) should retain this page for their information)

1.As a prerequisite to holding a wholesale representative’s licence, the employer must hold a current restricted drug manufacturer or restricted drug wholesaler licence in Queensland or an equivalent interstate licence.

2.Licences for wholesale representatives are forwarded to the applicant. Employers will need to obtain a copy of the licence from the wholesale representative (applicant), as copies are not provided by Queensland Health.

3.A Licence as a Wholesale Representative is valid for 12 months, from the date of issue unless otherwise suspended, cancelled or surrendered.

4.An authorised employer must sign Section 9 of this form Employer Information section. Queensland Health is not able to accept a photocopy or fax of that page unless it bears the original signature of the authorised signatory.

How to complete Employer sections of the application

Please each checkbox below as you complete the application form to ensure that you have provided the necessary particulars.

Section 6Employer details

Incorporated companies: Advise the name that appears on the Certificate of Incorporation issued by ASIC.

Attach a copy of the document to the application only if it has not previously been provided.

Provide the Australian Company Number (ACN) as it appears on the Certificate of Incorporation.

Section 7Business address

Attach a copy of the Business Names Extract issued under the Business Names Act 1962.

Provide address details, telephone number and contact details of thebusiness and person responsible for licence.

Section 8Poisons licence

Advise the drugs/poisons licence issued by Queensland Health or Interstate equivalent licences, check the appropriate box.

Section 9Declaration

The form is signed and dated by a person who has authority from the Employer (other than the applicant).

Credit Card Payments

Use this sheet only if payment is being made by this method. Do not return this page if payment is made by cheque or money order.

The card number is accurate and legible1. Do not overwrite any digits.

The expiry date is completed and the card has not lapsed1. Do not overwrite any digits.

The cardholder has signed and dated the form.

1 If an error is made, cross through the digit using a single line, write the correct digit above and initial the change.

Form HDPR96.04-Dec 2011