(1)
The National Drug Policy and Authority (Issue of Licences) Regulations, S.I 206- 3 is revoked.
(2)
Regulation 16 of SI 206 - 1 is revoked.
Application for a Licence to Sell Class C Drugs
Physical address of premises _____________________________________ P. O. Box No. ______________ Tel. ______________ Fax ______________ Name of applicant _________________________________________ Qualifications-(pharmaceutical) __________________________________ (Other) ______________________________________________________
Is the application made for- (a) an individual ____________________________________________ (b) a partnership ___________________________________________ (c) a company ______________________________________________ (tick as appropriate)
If applying on behalf of a company- Physical address of registered office__________________________________ P.O. Box No._____________ Tel. _______________ Fax _______________ Name of managing director ________________________________________
If applying on behalf of a company or partnership, give the following information for all partners or directors- Name _________________________________________________________ Address________________________________________________________ Qualification____________________________________________________
Has the applicant or any partner or director been convicted, of any offence involving the wrongful or illegal dealing or supply or possession of drugs within or outside Uganda? Yes/No If "yes", give details ______________________________________________ Has any previous application by the applicant, or any partner or director, for a licence to operate any type of business under the Act been refused or cancelled? Yes/No
If "yes", give details ______________________________________________
Does the applicant or any partner or director currently hold a licence to operate any type of business under the Act, including the business of selling class C drugs, at any other premises? Yes/No
If "yes", give details _____________________________________________ Name of person to be in charge of the premises ________________________ Qualification/training ____________________________________________
I have been informed of and understand the restrictions on the range of drugs and drugs which may be sold by a class C drug shop.
I certify that the above information is correct and apply for a licence to sell Class C drugs at the above-named premises.
Signature of applicant ________________ Date _______________
Suitability of premises certificate checked Yes/No ______________________
Applicant's information checked and verified Yes/No ___________________________________________________ (signature)
Licence to operate a class C drug shop for selling of drugs included in the Third Schedule of the Act.
Approved/not approved ___________________________________________
If not approved, give reasons _______________________________________
________________________________ __________________________ _ For the Authority Date
Application For a Licence to Operate Retail Pharmacy.
Physical address of premises ____________________________________ P.O. Box No. ______________ Tel. ______________ Fax ______________ Name of applicant _______________________________________________ Qualifications- (pharmaceutical) ________________________________________________ (Other) _______________________________________________________ Application is made fora partnership ____________________________________________________ a company _____________________________________________________
If applying on behalf of a company- Physical address of registered office_________________________________ P.O. Box No. _____________ Tel. _______________ Fax ______________
Name of managing director ________________________________________ If applying on behalf of a company or partnership, give the following information for all directors or partners - Name__________________________________________________________
Address________________________________________________________
Qualifications___________________________________________________ Has the applicant or any partner or director been convicted , of any offence involving the wrongful or illegal dealing in or supply or possession of drugs within or outside Uganda? Yes/No If "yes", give details _____________________________________________
Has any previous application by the applicant, or any partner or director, for a licence to operate any type of business under the Act, including the business of selling class C drugs, been refused or cancelled? Yes/No If "yes", give details ______________________________________________
Purposes for which premises are to be used (tick proposed activities)- retail pharmacy __________________________________________________ dispensing prescriptions ___________________________________________ compounding for prescription ______________________________________ compounding for retail sale ________________________________________ packing ________________________________________________________ Name and registration number of pharmacist to be in charge of the premises _____________________________________________________________
I certify that the above information is correct and apply for a licence to operate retail pharmacy at the above-named premises.
Signature of applicant_____________________________________________ Date_________________________________________________________
Suitability of premises certificate checked Yes/No
____________________________________________________ (signature)
Applicant's information checked and verified Yes/No ___________________ Licence to operate a retail pharmacy approved/not approved
If not approved, give reasons _______________________________________
________________________________ _________________________ For the Authority Date
Application for a Licence to Operate Wholesale Pharmacy.
Physical address of premises ______________________________________ P. O. Box No. _______________ Tel. _____________ Fax ______________ Name of applicant _______________________________________________ Qualifications - (pharmaceutical) ________________________________________________ (Other) ________________________________________________________
Is the application made fora partnership ____________________________________________________ a company _____________________________________________________
If applying on behalf of a company__________________________________ Physical address of registered office________________________________ P. O. Box No. _______________ Tel. _______________ Fax ____________ Name of managing director __________________________________
If applying on behalf of a company or partnership, give the following information for all the directors or partners -
Name_________________________________________________________ Address________________________________________________________ Qualifications___________________________________________________
Has the applicant or any partner or director been convicted, of any offence involving the wrongful or illegal dealing in or supply or possession of drugs within or outside Uganda? Yes/No
If "yes", give details ____________________________________________
Has any previous application by the applicant or any partner or director for a licence to operate any type of business under the Act, including the business of selling class C drugs, been refused or cancelled? Yes/No
If "yes", give details ______________________________________________
Will a retail pharmacy be operated from the same premises? Yes/No
Does the applicant or any partner or director currently hold a licence to operate any type of business under the Act, including the business of selling class C drugs, at any other premises? Yes/No
Will the licensed person import drugs from outside Uganda? Yes/No
Will the business sell human drugs/veterinary drugs/both? Name and registration number of pharmacist to be in charge of the business _______________________________________________________________
I certify that the above information is correct and apply for a licence to operate a wholesale pharmacy at the above-named premises.
Signature of applicant____________________________________________ Date__________________________________________________________
__________________________________ __________________________ For the Authority Date
Application For a Licence to Manufacture Drugs
Physical address of premises _______________________________________ P. O. Box No. _______________ Tel. ______________ Fax _____________ Name of applicant ___________________________________________ Qualifications (pharmaceutical) ___________________________________ (Other) ______________________________________________________
Is the application made fora partnership ____________________________________________________ a company _____________________________________________________
If applying on behalf of a company-
Physical address of registered office ________________________________ P. O. Box No. _______________ Tel. ______________ Fax _____________ Name of managing director ________________________________________
If applying on behalf of a company or partnership give the following information for all partners or directors-
Name__________________________________________________________
Address________________________________________________________
Qualifications___________________________________________________ Has the applicant or any partner or director been convicted, of any offence involving the wrongful or illegal dealing in or supply or possession of drugs within or outside Uganda? Yes/No
If "yes", give details ____________________________________________
Has any previous application by the applicant, or any partner or director, for a licence to operate any type of business under the Act been refused or cancelled? Yes/No
If "yes", give details ______________________________________________
Does the applicant or any partner or director currently hold a licence to operate any type of business under the Act, including the business of selling class C drugs, at any other premises? Yes/No
If "yes", give details ______________________________________________
Name and registration number of the pharmacist in charge of the manufacturing processes _________________________________________
Name and registration number of pharmacist or name of the chemist to be in charge of quality control and assurance _______________________________
Names, qualifications and registration number of the other pharmacists employed and names of the other or chemists employed _________________
I certify that the above information is correct and apply for a licence to manufacture drugs at the above-named premises.
______________________________ _____________________ Signature of applicant Date
Suitability of premises certificated checkedYes/No
____________________________________________________ (Signature)
Applicant's information checked and verified Yes/No _____________________________________________________ (Signature)
Licence to manufacture drugs approved/not approved If not approved, give reasons _______________________________________.
_____________________________ ___________________________ For Authority Date
FORM 20 Regulations 19 (4)
Application for Assessment for Compliance with Good Manufacturing Practice Guidelines
(A separate application form should be filled for each site)