Description of required information

The following information is to be inserted in the corresponding section of the application form:

  1. Full Name(s) of Applicant: The full name of the legal entitythat is applying for the licence or permit, e.g. the name of the company or incorporated body (for a corporate entity) or the full name of the proprietor (for a sole trader) or of all partners where a business is not incorporated.Provide a copy of any supporting documents, (e.g.Certificate of Incorporation) including a list of the names of all directors, if applicable.Indicate also the type of legal entity.
  2. Australian Company Number (ACN): If the applicant is a company or incorporated entity.
  3. Business or Trading Name of Applicant: The registered business or trading name, if any.Provide a copy of any supporting documents, (e.g. Certificate of Registration of Business Name).
  4. Australian Business Number (ABN):If the applicant is so registered.
  5. Registered Business Address of Applicant: The business address or the address of the registered office of an incorporated body.
  6. Contact Details of Applicant: The contact details at the business address of the applicant.
  7. Postal Address for Correspondence to Applicant: The preferred mailing address of the applicant.
  8. Address of the Primary Premises to which this application relates: The address of the primary location where the poisons are to be manufactured, sold/supplied, indent-sold/supplied, stored or used. If more than one location is involved, a separate application may be required for each location.Contact Drugs and Poisons Regulation for advice.Note: This address is NOT the address of any third-party warehouse if poisons are to be sold or supplied by indent.
  9. Contact Details of the Primary Premises to which this application relates:The contact details at the primary location to which the application relates.
  10. Readiness for Inspection: An indication of whether/when the premises will be ready for inspection.
  11. The Poisons or Controlled Substances to which this application relates: The schedule(s) of poisons or controlled substances that are justifiably required by the applicant, as listed in the Commonwealth Standard, the Standard for Uniform Scheduling of Medicines and Poisons (the SUSMP)(current version, including any amendments). The SUSMP may be accessed at
  • Schedule relates to the schedules in the SUSMP,
  • Select AllorLimitedto indicate the range of poisons or controlled substances within a schedule that is required. Provide written justification for your selections, whether All or Limited.
  • The term‘Drugs of Dependence’relates,in Victoria,to those poisons or controlled substances that are listed in Schedule 11 of the Drugs, Poisons and Controlled Substances Act 1981 (the Act). In Schedule 3, this is only relevant to Pseudoephedrine. In Schedule 4, Schedule 8 and Schedule 9, refer to the list in Schedule 11 of the Act. The Act may be viewed at or via a link from the website of the Department of Health Drugs and Poisons Regulation at
  • The term ‘Listed Regulated Poison’ in Schedule 7 relates, in Victoria to a Schedule 7 poison that is listed in Part 2 of the Victorian Poisons Code as a poison that is not for general sale by retail.
  • The Victorian Poisons Code may be viewed at
  1. Type of licence or permit to which this application relates: Indicate the type of licence or permit to which this application relates.Select only onetype of licence or permit per application. For licences, a separate application is required for a licence for Schedule 8 and/or Schedule 9 poisons to that for a licence for Schedule 2, Schedule 3, Schedule 4 and/or Schedule 7 poisons.
  2. Declaration by person completing application:A full and frank disclosure of any guilty findings of indictable offences by the applicantis required.This declaration is to be completed and signed by the applicant in the presence of an adult(i.e.18 years and older) witness.

Required documentation

Before your application can be processed, the following must be completed and submitted:

  1. Licence or Permit Application Form (ORIGINAL, not a copy) (document completed in all details, including provision of any supporting documentation – see also point 1), and
  2. Poisons Control Plan (completed in all relevant details), and
  3. Application to Nominate a Responsible Person (ORIGINAL, not a copy) (completed in all details, including provision of requested supporting documentation)

Copies of the following supporting documents are also required (where applicable):

  • Certificate of incorporation (where the applicant is a corporate entity) or ASIC information
  • List of all directors (of the corporate entity), list of all partners (if non-incorporated),
  • Certificate of registration of business/trading name,
  • Non Emergency Patient Transport (NEPT) licence
  • Commonwealth Therapeutic Goods Manufacturing licence
  • Australian Pesticides and Veterinary Manufacture Authority (AVMPA) permit

Submission of application

The prescribed feemust accompany every application (see table of fees – GST does not apply to these fees, i.e. application fees are GST-free) and should be forwarded, with ALL required documents to:

CHIEF OFFICER

DRUGS AND POISONS REGULATION

DEPARTMENT OF HEALTH

GPO BOX 4541

MELBOURNE 3001

For any further information - Phone: 1300 364 545 or Email:

All details to be completed

1.Full Name(s) of Applicant (i.e. the ‘Legal Entity’):
(Please indicate also the type of legal entity)
Company Incorporated Body Sole Trader Partnership
2. Australian Company Number (ACN)(if applicable):
3. Business or Trading Name of Applicant (if applicable):
4. Australian Business Number (ABN) (if applicable):
5. Registered Business Address of Applicant:
6. Contact Details of Applicant:
(a) Telephone Number(s):
(b) Facsimile Number:
(c) Email Address:
7. Postal Address for Correspondence to Applicant:
8. Address of the Primary Premises to which this application relates:
9. ContactDetails of the Primary Premises to which this application relates (if applicable, put ‘As Above’):
(a) Telephone Number(s):
(b) Facsimile Number:
(c) Email Address:
10.Readiness for Inspection:
The applicant’s premises: are ready for inspection now
will be ready for inspection after //

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Department of Health

11. The Poisons or Controlled Substances to which this application relates:
Schedule 2 All or Limited
Schedule 3 All or Limited includingPseudoephedrine in Schedule 3 Yes or No
Schedule 4 All or Limited includingDrugs of Dependence in Schedule 4 Yes or No
Schedule 7 All or Limited includingListed Regulated Poisons in Schedule 7 Yes or No
Schedule 8 All or Limited
Schedule 9 All or Limited
If only a limited range of poisons within a schedule is required, then a list may be provided on a separate sheet of paper affixed to this application form.
Whether ‘All’ or ‘Limited’ is selected, justification forallselected substances will be required by the department.
Notes:
  • For licences, aseparate application is required for a licence for Schedule 8 and/or Schedule 9 poisons to that for a licence for Schedule 2, Schedule 3,Schedule 4 and/or Schedule 7 poisons.
  • An independent security audit report may be required to accompany an application for Schedule 8 and/or Schedule 9 poisons.
12. Type of licence or permit to which this application relates:
Note: A complete application form (includingoriginal signatures) is required to be submitted for eachlicence or permit.
Selectone (only)type of licence or permit for which you are applying.
Licence to:
Manufacture and Sell or Supply by Wholesale
Sell or Supply by Wholesale
Sell or Supply by Wholesale, by IndentOnly
Sell or Supply by Retail Schedule 2 poisons
Manufacture and Sell or Supply byRetail,Schedule 7 poisons (other than a listed regulated poison)
Note:‘Indent’refers to a licence to sell or supply poisons or controlled substances where the licence holder does not take possession.
Permit to:
Purchase or Obtain Poisons or Controlled Substances for Use for Industrial, Educational, Advisory or Research Purposes
Purchase or Obtain Poisons or Controlled Substances for the Provision of Health Services
13. Declaration by person completing application:
I,
(provide full name)
of:
(provide full address)
hereby declare that:
(a) The applicant hasnot been found guilty of an indictable offence in the past ten years, save and except for those offences declared below.
Note: An indictable offence is an offence deemed to be an indictable offence under section 2B of the Crimes Act 1958 (Vic.)
The details of any guilty finding(s) are as follows:
Date: / / Offence:
Court: Penalty:
and,
(b) I am duly authorised to complete and sign this application on behalf of the applicant, and
(c) Where drugs of dependence are being applied for in this application, a National Police Record Check has
been or will be carried out for the applicant in relation to each person who will have unsupervised access to
those drugs, and
(d) The information that I have supplied in this application is true and correct in every particular and that this
declaration is made in the knowledge that a person making a false declaration is liable to prosecution under
Section 49 of the Drugs, Poisons and Controlled Substances Act 1981.
Signed:
(signature)
at:
(address where declaration signed)
on the: day of:
and witnessed in the presence of:
(print full name of adult witness)
(signature of adultwitness)

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Department of Health