Poisons Licence

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Form of application by a person to have their name entered in a local authority's list of persons entitled to sell non-medical poisons in part ii of the poisons list

I, (your name)
being engaged in the business of
hereby apply to have my name entered in the list kept in pursuance of section 5 of the above Act in respect of the following premises, namely,

as a person entitled to sell from those premises poisons included in Part II of the Poisons List.

I hereby nominate

to act as my deputy (deputies) for sale of non-medical poisons in accordance with Rule 10(1) of the poisons Rules 1978.

Signature (Print) of applicant:

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