PHARMACY APPLICATION FORM - Pharmacy Council Ghana
PHARMACY APPLICATION FORM - Pharmacy Council Ghana
PHARMACY APPLICATION FORM - Pharmacy Council Ghana
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<strong>PHARMACY</strong> <strong>APPLICATION</strong> <strong>FORM</strong><br />
PAI<br />
…………………………………………………………………………………………………………hereby apply<br />
(SURNAME) (First Name) (Middle Name)<br />
to register……………………………………………………………………………………………………………..<br />
(NAME OF <strong>PHARMACY</strong>)<br />
As a ……………………………………………………………………………………………<strong>Pharmacy</strong> Business<br />
(Retail, Wholesale or Wholesale/Retail)<br />
LOCATION ADDRESS<br />
H/No. …………………………………………………………….. Town:……………………………………………………………<br />
Street name:…………………………………………………… District:……………………………………………………….<br />
Landmark………………………………………………………… Region:…………………………………………………………<br />
Suburb:……………………………………………………………<br />
BUSINESS PARTICULARS<br />
POSTAL ADDRESS:<br />
TELEPHONE:<br />
FAX:<br />
E-MAIL:<br />
PROPOSED BUSINESS HOURS<br />
MONDAYS - FRIDAYS SATURDAYS SUNDAYS<br />
SHAREHOLDERS/PARTNERS: 1. ………………………………………………<br />
2. ………………………………………………<br />
3. ……………………………………………….<br />
DIRECTORS<br />
SIGNATURE<br />
Names of other Pharmacies owned<br />
Town/District/Region<br />
NB: If this proposed <strong>Pharmacy</strong> shall be a branch of an existing <strong>Pharmacy</strong>, this application MUST be<br />
supported with Registrar General’s Documents specifically for this proposed <strong>Pharmacy</strong>.<br />
……………………………………………………………<br />
(Name of Applicant/Company Representative)<br />
Designation:……………………………………<br />
Signature:……………………………………….<br />
Date:………………………………….<br />
NB: PROPOSED SUPERINTENDENT PHARMACIST MUST HAVE DONE AT LEAST 12 MONTHS OF POST –<br />
REGISTRATION PRACTICE IN GHANA AND MUST BE EMPLOYED FULL TIME FOR THIS PROPOSED <strong>PHARMACY</strong>.<br />
TO BE COMPLETED BY PROPOSED SUPERINTENDENT PHARMACIST.<br />
I wish to certify that all the above information is correct to the best of my knowledge and hereby accept to be the Superintendent<br />
Pharmacist for the business.<br />
…………………………………………………<br />
(NAME OF PROPOSED SUPERINTENDENT PHARMACIST)<br />
………………………………………………<br />
(Registration Number)<br />
……………………………………………………………<br />
(Signature)<br />
…………………………………………………………<br />
(Date)<br />
PLEASE NOTE: Any false declaration or the provision of any false information will render<br />
this application invalid.<br />
15
LOCATION CLEARANCE <strong>FORM</strong><br />
PAII<br />
NAME OF APPLICANT………………………………………………………………………………………………………<br />
(SURNAME) (First Name) (Middle Name)<br />
POSTAL ADDRESS<br />
TELEPHONE:<br />
FAX:<br />
E-MAIL:<br />
PROPOSED BUSINESS NAME: ………………………………………………………………………………………….<br />
TYPE OF <strong>PHARMACY</strong> BUSINESS RETAIL WHOLESALE WHOLESALE/RETAIL<br />
LOCATION ADDRESS<br />
H/No. ……………………………………………………………..<br />
Street name:……………………………………………………<br />
Landmark…………………………………………………………<br />
Suburb:……………………………………………………………<br />
DIMENSION OF STORE: LENGTH: ……………… WIDTH: ………………..<br />
HEIGHT: ………………..<br />
TOWN:…………………… DISTRICT:…………………………… REGION:……………………………<br />
NAME OF NEAREST <strong>PHARMACY</strong>/PHARMACIES<br />
1.<br />
2.<br />
3.<br />
RELATIVE DISTANCE FROM PROPOSED<br />
LOCATION<br />
SKETCH OF LOCATION<br />
PLEASE NOTE: Any false declaration or the provision of any false information will render<br />
this application invalid.<br />
16
DATA ON PHARMACISTS<br />
PROPOSED SUPERINTENDENT PHARMACIST<br />
PA III<br />
NAME: …………………………………………………….<br />
<strong>FORM</strong>ER NAME (if any)…………………………………<br />
REG. NO.:…………………………<br />
SIGNATURE:……………………<br />
MONTH & YEAR OF REG.:…………...<br />
POSTAL ADDRESS RESIDENTIAL ADDRESS TEL:<br />
FAX:<br />
Current Place(s) of<br />
Work<br />
E-MAIL:<br />
WORK HISTORY<br />
CURRENT PLACE(S) OF WORK<br />
COMPLETE EACH ROW AS IT APPLIES TO YOU.<br />
POSITION HELD<br />
NAME & LOCATION<br />
(TOWN/REGION) OF<br />
INSTITUTION<br />
1<br />
2<br />
FROM – TO<br />
(Month &<br />
Year)<br />
WORKING<br />
HOURS<br />
Community<br />
<strong>Pharmacy</strong><br />
Hospital<br />
Medical<br />
Representative<br />
Academia<br />
Others, industry,<br />
Administration etc.<br />
(Please specify)<br />
PREVIOUS PLACES OF WORK<br />
COMPLETE EACH ROW AS IT APPLIES TO YOU.<br />
POSITION HELD<br />
NAME & LOCATION<br />
(TOWN/REGION) OF<br />
INSTITUTION<br />
1.<br />
2.<br />
3.<br />
4.<br />
1.<br />
2.<br />
1.<br />
2.<br />
1.<br />
2.<br />
FROM – TO<br />
(Month & Year)<br />
WORKING<br />
HOURS<br />
PLEASE NOTE: Any false declaration or the provision of any false information will render<br />
this application invalid.<br />
17
FOR OFFICIAL USE ONLY (not to be filled by applicant)<br />
PA – IV<br />
1. LOCATION IN<strong>FORM</strong>ATION IN RESPECT OF ……………………………………………………<br />
(NAME OF <strong>PHARMACY</strong>)<br />
2. LOCATION ADDRESS<br />
H/No. …………………………………………………………….. District:…………………………………………………………….<br />
Street name:…………………………………………………… GPS: Latitude: ……………………………………..<br />
Landmark………………………………………………………… Longitude: ……………………………………..<br />
Suburb:……………………………………………………………<br />
Town:…………………………………………………………….<br />
3. How many facilities are in the Area?<br />
Degrees: …………………………………………..<br />
Altitude: (Storey Building? Which floor?)<br />
………………………………………………..<br />
District<br />
Town<br />
Suburb<br />
Pharmacies L.C.S Other Health Facilities(e.g. Health Post,<br />
Clinics, Hospitals etc)<br />
4. How far are the three (3) nearest facilities from the proposed site?<br />
<strong>Pharmacy</strong> Distance LCS Distance Health Facilities Distance<br />
5. Give a sketch below showing the relative positions and distances of the proposed site and the<br />
existing facilities/Landmark.<br />
PLEASE NOTE: Any false declaration or the provision of any false information will render<br />
this application invalid.<br />
18
Please list any other application(s) received for or near the proposed site and reflect it/them on<br />
the sketch.<br />
Diagram here<br />
PLEASE NOTE: Any false declaration or the provision of any false information will render<br />
this application invalid.<br />
19
PA –V<br />
6. APPROXIMATE POPULATION SUBURB ………………………………………………………………………….<br />
7. What peculiar activity is within/around the proposed site? (e.g. Market, Lorry Station etc.)<br />
…………………………………………………………………………………………………………….<br />
8. Room dimension: Length………………………Width……………………Height………………………<br />
Total Floor Space ……………………………………………………………………………….<br />
9. Any other comments:<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
……………………………………………………………………………………………………………………………………<br />
10. Recommendation:……………………………………………………………………………………………<br />
…………………………….<br />
NAME OF INSPECTOR<br />
…………………………………<br />
SIGNATURE<br />
…………………………………<br />
DATE<br />
………………………………………<br />
NAME OF REGIONAL/ZONAL MANAGER<br />
…………………………………<br />
SIGNATURE<br />
…………………………………<br />
DATE<br />
REGISTRATION COMMITTEE’S RECOMMENDATION<br />
COUNCIL’S DECISION<br />
Recommended Not Recommended Deferred<br />
Referred to <strong>Council</strong><br />
APPROVED<br />
Deferred<br />
NOT APPROVED<br />
SIGN:……………………………………………<br />
SIGN:…………………………………<br />
DATE:……………………………………………<br />
DATE:…………………………………<br />
PLEASE NOTE: Any false declaration or the provision of any false information will render<br />
this application invalid.<br />
20
FOR OFFICIAL USE ONLY (not to be detached)<br />
PA VI<br />
NAME OF INSPECTOR<br />
OR AUTHORIZED<br />
OFFICER<br />
DATE OF RECEIPT<br />
CODE NUMBER<br />
PLEASE NOTE: Any false declaration or the provision of any false information will render<br />
this application invalid.<br />
21
FOR OFFICIAL USE ONLY (to be completed at point of submission)<br />
PA VII<br />
SUBMISSION OF <strong>APPLICATION</strong> <strong>FORM</strong><br />
REGIONAL OFFICE: …………………………………………….<br />
DATE OF SUBMISSION: ……………………………………………<br />
PROCESSING FEE PAID: …….. …………………………………<br />
RECEIPT NO. : ……………………………………………………….<br />
SIGNATURE OF RECEIVING OFFICER: …………………………..<br />
NAME: ………………………………………………………………….<br />
This page should not be detached<br />
PLEASE NOTE: Any false declaration or the provision of any false information will render<br />
this application invalid.<br />
22
PA –VIII<br />
FOR OFFICIAL USE ONLY BY P.L.E.D.<br />
Date of Receipt by<br />
Regional Office<br />
Date on which site<br />
inspection was conducted<br />
P.L.E.D.’s Date of Receipt<br />
Date on which<br />
Registration Committee<br />
Considered application<br />
Date on which council<br />
decided on application<br />
Date on which council’s<br />
decision was despatched<br />
to the regions<br />
Date on which final<br />
inspection was conducted<br />
Date on which PLED<br />
received Final Inspection<br />
Report<br />
Date on which Licence<br />
was printed<br />
Date on which licence was<br />
sent to the region<br />
PLEASE NOTE: Any false declaration or the provision of any false information will render<br />
this application invalid.<br />
23
OFFICIAL STAMP<br />
ACKNOWLEDGEMENT SLIP (TO BE DETACHED AND GIVEN TO APPLICANT)<br />
PA IX<br />
DATE OF RECEIPT<br />
………………………………………………..<br />
NAME OF INSPECTOR/AUTHORISED OFFICER<br />
…………………………………………………..<br />
CODE NUMBER<br />
TIME<br />
SIGNATURE:<br />
IN CASE OF ANY ENQUIRES CONCERNING THIS <strong>APPLICATION</strong>, PLEASE CONTACT <strong>PHARMACY</strong> COUNCIL ON THE<br />
FOLLOWING ADDRESSES AND TELEPHONE LINES AS IT APPLIES TO YOU.<br />
PREMISES, LICENSING AND ENFORCEMENT DEPARTMENT (P.L.E.D.)<br />
POSTAL ADDRESS: P. O. Box AN10344, Accra – North, <strong>Ghana</strong>, Tel: 681929/ 680150; FAX: (233-21) 681931<br />
TELEPHONE:<br />
Greater Accra (233-21) 671427 The Regional Manager<br />
<strong>Pharmacy</strong> <strong>Council</strong><br />
Kwame Nkrumah Avenue<br />
Near Adjabeng Court<br />
P.O. Box AN 10344<br />
Accra – North<br />
Ashanti Region (233-51) 31636/41455 The Regional Manager<br />
<strong>Pharmacy</strong> <strong>Council</strong><br />
Regional Health Administration<br />
P.O. Box KS 778<br />
Kumasi<br />
Northern Zone (233-71) 23061 The Zonal Manager<br />
<strong>Pharmacy</strong> <strong>Council</strong><br />
Tamale Old Hospital<br />
P.O. Box TL 1777<br />
Tamale<br />
Western Region (233-31) 46391 The Regional Manager<br />
<strong>Pharmacy</strong> <strong>Council</strong><br />
Regional Health Administration<br />
Sekondi<br />
Volta Region (233-91) 26324 The Regional Manager<br />
<strong>Pharmacy</strong> <strong>Council</strong><br />
Old School of Hygiene<br />
P.O. Box HP 1266<br />
Ho<br />
Brong Ahafo (233-61) 26551 The Regional Manager<br />
<strong>Pharmacy</strong> <strong>Council</strong><br />
Regional Health Administration<br />
P.O. Box 744<br />
Sunyani<br />
Central Region (233-42) 33233 The Regional Manager<br />
<strong>Pharmacy</strong> <strong>Council</strong><br />
SIC Building Complex<br />
Near STC Yard<br />
P.O. Box CC 1339<br />
Cape Coast<br />
Eastern Region (233-81) 24699 The Regional Manager<br />
<strong>Pharmacy</strong> <strong>Council</strong><br />
2 nd Floor SIC Office Complex<br />
P.O. Box KF 2228<br />
Koforidua<br />
PLEASE NOTE: Any false declaration or the provision of any false information will render<br />
this application invalid.<br />
24
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