Medicines, Poisons and Therapeutic Goods Licence Amendment

About this form

This form is to be used to apply for an amendment to a licence under the Medicines, Poisons and Therapeutic Goods Act 2008.

This application form must be completed by the licence holder.

All associated documentation must accompany this application form.

Your original licence certificate must be returned to the Health Protection Service.

You cannot amend the licence holder with this form. A new application must be submitted.

Fees

An amendment fee of $38 may be paid by Visa or MasterCard.

Payment options

Visa and MasterCard logos

Payments up to $10,000 can be made with either Visa or MasterCard.

Your personal information

Access Canberra uses this form to collect information which is necessary to allow the ACT Government to provide services to you. Personal Information may be used or disclosed in accordance with the Information Privacy Act 2014.

For details on the collection of personal information in this form please refer to the Access Canberra Information Collection Notice. If you have questions about how your information will be handled please see the Access Canberra Privacy Policy and the ACT Health Privacy Notice or contact us.