How to Draft Application for Pharmacy premises in Tanzania.

Posted by By sheriazetu.com 16 August 2023 4 Min Read

PHARMACY COUNCIL
APPLICATION FOR REGISTRATION AND RE REGISTRATION OF PREMISES
TICK WHERE APPROPRIATELY REGISTRATION REREGISTRATION
SECTIONA: APPLICANT INFORMATION

  1. Name of contact
    person:…………………………..………………………….………………………………………
    ……..
  2. Postal address…………………………………………. Tel No………….…………………
    Email………………………………….
  3. I/We hereby apply for a new or re-registration of premises for pharmacy business of:
    (tick)
    (a) Community Pharmacy
    (b) Wholesale Pharmacy
    (c) Consultant pharmacy
    (d) Storage facilities
    (e) Vessel
    SECTION B: OWNERSHIP
  4. Type of ownership (tick)
    (a) sole proprietorship (ONLY for owners who are pharmacist);
    (b) partnerships;
    (c) corporations;
    (d) joint ventures; and or association.
    (e) others (mention):……………………………………………..
  5. The registration number of BRELA is
    ………………………………………………………………
  6. Full name(s) of Owner (s), Partner(s) and Directors(s)
    (a) Name: ……………………………………Qualification:…………………………… I.DNo……….

Name: ……………………………………Qualification:…………………………… I.D No…………………….. (c) Name: ……………………………………Qualification:…………………………… I.D No…………………….. (d) Name: ……………………………………Qualification:…………………………… I.D No…………………….. (e) Name: ……………………………………Qualification:…………………………… I.D No…………………….

PARTC: PREMISES INFORMATION

1. Name of the premises ………………………………………………………………

2. Premises situated at/lying between Plot No ………………….House No…………… Street name ………………………. Ward………………………District/Municipality/City ……………………………….. Region………………………………………

3. For re-registration, Facility Identification Number (FIN)…………………………….of (year)……………………. Expiring on………………………..existing Permit No………………… Dated………………..Expiring on …………………

4. SECTION D: MANDATORY REQUIRED ATTACHMENTS

1. Required attachment to be submitted with this form are-

(a) Memorandum and Article of Association with a pharmacist (if the owner is not a pharmacist);

(b) A copy of lease agreement/ title deed;

(c) A copy of Certificate of Registration from BRELA;

(d) Certified copy of Director(s)/Partner (s) ID with their current photograp

(e) A copy of the site plan of the building indicating the location of the pharmaceutical premises in relation to adjoining or surrounding businesses and access to and from such premises;

and (f) A copy of the plan layout of the actual pharmacy premises.

1. If my/our premises is registered and licensed I/We shall keep it in hygienic condition and good state as required under the above mentioned Act and Regulations made thereunder.

2. I/we have not been convicted of any offence relating to any provision of the Pharmacy Act, 2011 and Regulations made thereunder or any other written law related to the business being applied for within 12 months immediately preceding this application and have not been disqualified from holding a license/certificate and my license is not suspended.

3. I, the undersigned, do hereby declare that the particulars given above are correct and complete to the best of my knowledge and that any change of details shall be communicated to the Registrar in writing. N.B. False declaration constitutes an offence. _________________________________ _______________________________ Name and Signature of the Applicant Date of ApplicatioName: …

.

SECTION:
DISTRICT/MUNICIPAL/REGIONAL/PHARMACY COUNCIL INSPECTOR’s REMARKS

  1. (In case there is no District Inspector this part should be filled by Regional Inspector)
  2. I,
    Mr./Mrs./Ms./Dr./Prof:………………………………District/Municipal/Regional/PCI
    Inspector of Postal address:…………………………hereby certify that, I have
    inspected the above-mentioned premises in Section A as per attached inspection
    checklist and found that it complies/does not comply with standards prescribed for
    registration of premises.
    Please give reason(s) if it does not comply:
    ………………………………………………………………………….…..……………
    …………………………………………………………………………………………
    Name of Inspectors(s)
    Signatures &stamp
    Date
    1.………………………………
    …………………………
    ……………….
    2.……………………………….
    …………………………
    ……………….
    SECTION G: FOR OFFICIAL USE ONLY
    Fees TZS……………………………………..……Receipt No ………..……………….
    of…………………………
    Registration granted/not
    granted
    because…………………………..…………………………………….…………………
    Registration No……..……. Approved by Name:…………………………..……………………..
    Signature:……………………………………….
    Designation:
    …………………………………………………
    I.D
    Number:………………………………………………..
    Date:………………………………………….
    ……………….
    ………..…………………………….
    Signature of Registrar and stamp.