Application for a Licence to Deal in Controlled Drugs F Forward completed application to:
Medicines Control, PO Box 5013, WELLINGTON 6145
Pursuant to regulation 3 of the Misuse of Drugs Regulations 1977, I hereby apply for a Licence to Deal in the Controlled Drugs indicated on OR Name and postal address of body Name and postal address of individual corporate: applicant: Street address of applicant’s premises to which the licence is to apply:
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Distributor’s s name and address (if other than applicant):
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The licence is required to allow controlled drugs to be:
For Manufacture: Please provide the names, strengths and quantities of controlled drugs to be manufactured during the proposed licensing period (on a separate sheet iif required) __
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Nature of business and if supply is included, who the controlled drugs are to be supplied to: __
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Application for a Licence to Deal in Controlled Drugs v2.1 Medicines Control, Provider Regulation
RESPONSIBLE PERSONS
Details of persons nominated to be responsible persons: Name
Application for a Licence to Deal in Controlled Drugs v2.1 Medicines Control, Provider Regulation
Schedule to Application for Licence to Deal in Controlled Drugs
CONTROLLED DRUGS APPLICANT PROPOSES TO DEAL IN:- Class B, Part I
gamma hydroxybutyrate (GHB) morphine hydrochloride
tetrahydrocannabinols (THC) (except when contained in a Class C controlled drug) 2-methylamino-1-(3,4methylenedioxyphenyl) propane (MDMA)
Class B, Part II
methylphenidate hydrochloride ephedrine
Class B, Part III Class C, Part I Class C, Part II
dextropropoxyphene napsylate/hydrochloride (not being a Class C, Part V drug)
Class C, Part III Class C, Part IV Class C, Part V
dextropropoxyphene preparations (as described in Class C, Part V)
Other controlled drugs not listed above: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Application for a Licence to Deal in Controlled Drugs v2.1 Medicines Control, Provider Regulation
Appendix I
Applications from Research, Testing and Teaching Organisations
Physical address where CD safe is located: Building No. Department Teaching Institution
Name of the Code of Practice the institution works under: ___________________________________________________________________ How are the medicines and/or controlled drugs to be used? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Where are the medicines and/or controlled drugs purchased from? ___________________________________________________________________ Does the applicant import controlled drugs?
If yes, does the applicant obtain import permits?
What form of recordkeeping is kept on site? i.e. controlled drug register
___________________________________________________________________ If live animals are involved, what is the name of the veterinarian in charge or to whom the responsible persons work under the direction of? ___________________________________________________________________
Application for a Licence to Deal in Controlled Drugs vDRAFT2.1 Medicines Control, Provider Regulation
ALLERGY: Symptoms, Causes & Testing There are around 18 million allergy sufferers in the UK and the incidence across Europe has more than doubled in the last 20 years. With the exception of anaphylaxis and severe asthma attacks, the illnesses are more debilitating than life threatening and as such have remained a relatively low priority within the health service. With less than 100
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Application for a Licence to Deal in Controlled Drugs