e-form

Application for a Pharmacy Licence for Medicinal Products for Human Use

SECTION A: GENERAL INFORMATION

1. DETAILS OF PROPOSED LICENCE HOLDER

1a If Individual:

Name:

Surname:

ID or Passport Number:

1b If company:

Name:

Company registration number:

Legal and judicial representative of company:

Name:

Surname:

ID or Passport No.:

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2a LEGAL ADDRESS OF PROPOSED LICENCE HOLDER

[If an individual, include the address on your ID card below. If a company, include the company address registered with MFSA below.]

Name/No.:

Street:

Locality:

Postcode:

2b CONTACT ADDRESS FOR COMMUNICATION (if different from above)

Name/No.:

Street:

Locality:

Postcode:

3 DETAILS OF PROPOSED LICENCE HOLDER CONTACT

3a Name:

Surname:

3b Address of proposed licence holder if different from section 2a

Name/No.:

Street:

Locality:

Postcode:

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3c Telephone number:

Mobile Number:

Email Address:

SECTION B: SITE INFORMATION

4a Name of proposed pharmacy (site name):

4b Site Address of proposed pharmacy

Name/No.:

Street:

Locality:

Postcode:

4c Site contact (if different from section 3)

Name:

Surname:

Telephone number:

Mobile number:

Email Address:

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4d Additional site for storage

Name/No.:

Street:

Locality:

Postcode:

SECTION C: THE MANAGING PHARMACIST

5a Please give the following details of the person who is to carry out the function of Managing Pharmacist:

Name:

Surname:

Initials:

Pharmacy council registration number:

5b Contact Details

Telephone number:

Mobile number:

Email Address:

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SECTION D

DECLARATION

I/We apply for the grant of a Pharmacy Licence to the proposed holder named in this application form in respect of the activities to which the application refers, and undertake that:

1. The activities are to be only in accordance with the information set out in the application or furnished in connection with it.

2. As proposed licence holder, I am not a medical practitioner, dental surgeon or veterinary surgeon, nor do I have any business agreement with any of these professionals.

3. I am not in possession of another pharmacy licence.

4. To participate in any national pharmaceutical distribution or dispensing system that the Minister of Health may at any time wish to introduce.

5. The licence is to be subject to all the Standard Provisions applicable to Pharmacy Licences under regulations for the time being in force and which may come into force from time to time.

6. I declare that the particulars and information I have given in this form are correct and complete.

Signature of proposed licence holder or legal representative in case of company:

Kindly fill in the Declaration form at the following link http://www.medicinesauthority.gov.mt/onlineapplications
A Declaration form should be submitted for each signatory.

Date:

Name and Surname:
(BLOCK LETTERS)

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ANNEX A- DOCUMENTS TO BE ATTACHED WITH APPLICATION

1. Declaration of Managing Pharmacist (refer to Annex B).

2. Police conduct of proposed licence holder.

3. Site plan.

4. An exact total foot print (floor area) declaration endorsed by an architect for the pharmacy.

The premises plan and floor area declaration should cover all premises of the pharmacy including all areas used as clinics and any storage space connected with the pharmacy premises and thus covered by the proposed pharmacy licence.

5. Declaration from architect stating the exact distance measured as the shortest walking distance, from nearest other pharmacies in the same locality and neighbouring localities.

6. Comprehensive description of the layout and operation of premises available for the storage and dispensing of medicinal products.


If the applicant is a company:

7. Original Memorandum of Articles of company issued by MFSA.

Please note that a Malta Environment and Planning Authority permit must be supplied by applicant before pharmacy licence is issued.

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ANNEX B- MANAGING PHARMACIST DECLARATION FORM

I,

Registration number:

declare that I will be the Managing Pharmacist for:

Proposed pharmacy name:

Site Address of pharmacy

Street:

Locality:

Postcode:

I undertake to inform the Medicines Authority in writing of any replacement and/or locum pharmacists that may substitute me as the need arises. A signed declaration shall also be submitted when my duties at the above mentioned pharmacy are terminated.

Signature:

Kindly fill in the Declaration form at the following link http://www.medicinesauthority.gov.mt/onlineapplications
A Declaration form should be submitted for each signatory.

Date:

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