MAR. 28.

THE NEW ZEALAND GAZETTE.

4. General nature of the business :
5. Position of applicant (i.e., "owner" or "manager" of the
   business, as the case may be):
6. Exact address of place of business in respect of which
   license is sought:

Application is hereby made for the issue of a storekeeper's
Poison License to the above-named applicant(s) in respect of
the above-described place of business subject to the Poisons
Act, 1934, and the regulations thereunder.
Dated this day of ,19 .
Signature.
Received the prescribed fee of 3s. 6d.
Postmaster.
Forwarded to the Registrar :—
Recommended
Not recommended ${$ Cross out line which does not apply. $}$
Date:
Medical Officer of Health.
Inspector of Health.
Police Officer.

[Form No. 4.
The Poisons Act, 1934.

APPLICATION FOR RENEWAL OF STOREKEEPER'S POISON
LICENSE.

1. Full name (or names) of applicant(s):
2. Number of current license: S .

Application is hereby made for the renewal of the above-
numbered Storekeeper’s Poison License. The current license
is enclosed herewith.
Dated this day of ,19 .
Signature.
Received the prescribed fee of 2s. 6d.
Postmaster.
Forwarded to the Registrar :—
Recommended
Not recommended ${$ Cross out line which does not apply. $}$
Date:
Medical Officer of Health.
Inspector of Health.
Police Officer.

[Form No. 5.
The Poisons Act, 1934.

APPLICATION FOR A STOREKEEPER'S EXTENDED POISON
LICENSE.

1. Full name of applicant:
2. Postal address of applicant:
3. Firm name under which is carried on the business in respect
   of which license is sought:
4. General nature of the business:
5. Position of applicant (i.e. “owner” or “manager” of the
   business, as the case may be):
6. Exact address of place of business in respect of which
   license is sought:

The said place of business is distant not less than five miles
by the nearest practicable route from the open shop of the
nearest chemist or from the open shop of any other holder
of a storekeeper’s extended poison license.
(a) The applicant is the holder of a wholesaler’s (or store-
keeper’s) poison license No. in force until 31st
March, 19 .
(b) The applicant is also applicant for a wholesaler's (or
storekeeper’s) poison license.
[Cross out either paragraph (a) or (b) as case may require.]

Application is hereby made for the issue of a Storekeeper’s
Extended Poison License to the above-named applicant in
respect of the above-described place of business subject to
the Poisons Act, 1934, and the regulations thereunder.
Dated this day of 19 .
Signature.

This is to certify that the above-named applicant [Full name
of applicant] is personally well known to me and is a person
of good character and sober habits and I consider him a fit
and proper person to be allowed to sell poisons.
Dated this day of ,19 .
Signature of a Justice of the Peace
or other responsible person satis-
factory to the Registrar.
Received the prescribed fee of £1.
Postmaster.
Forwarded to the Registrar :-
Recommended
Not recommended ${$ Cross out line which does not apply. $}$
Date:

Medical Officer of Health.
Inspector of Health.
Police Officer.

E

805

[Form No. 6.

Poisons Act, 1934.

APPLICATION FOR RENEWAL OF STOREKEEPER'S EXTENDED
POISON LICENSE.

1. Full name of applicant:
2. Number of current license: SX .

Application is hereby made for the renewal of the above-
numbered Storekeeper’s Extended Poison License.
The current license is enclosed herewith.
Dated this day of ,19 .
Signature.

This is to certify that the above-named applicant [Full name
of applicant] is personally well known to me and is a person
of good character and sober habits and I consider him a fit
and proper person to be allowed to sell poisons.
Dated this day of ,19 .
Signature of a Justice of the Peace
or other responsible person satis-
factory to the Registrar.
Received the prescribed fee of 10s.
Postmaster.
Forwarded to the Registrar :-
Recommended
Not recommended ${$ Cross out line which does not apply. $}$
Date:

Medical Officer of Health.
Inspector of Health.
Police Officer.

License No. W

Poisons Act, 1934.

WHOLESALE.R'S POISON LICENSE.

Pursuant to the above-entitled Act, a Wholesaler’s Poison
License is hereby granted to , of , in the
capacity of , in respect of the business known as ,
at the address

This license or its renewal as endorsed hereon shall unless
sooner revoked remain in force until the 31st day of March
next succeeding the date of issue or renewal.
Dated this day of ,19 .
Registrar.

License No. S.

Poisons Act, 1934.

STOREKEEPER’S POISON LICENSE.

Pursuant to the above-entitled Act, a Storekeeper’s Poison
License is hereby granted to , of , in the
capacity of , in respect of the business known as ,
at the address

This license or its renewal as endorsed hereon shall unless
sooner revoked remain in force until the 31st day of March
next succeeding the date of issue or renewal.
Dated this day of , 19 .
Registrar.

License No. SX .

Poisons Act, 1934.

STOREKEEPER'S EXTENDED POISON LICENSE.

Pursuant to the above-entitled Act a Storekeeper’s Extended
Poison License is hereby granted to , of , in
the capacity of , in respect of the business known as
, at the address

This license or its renewal as endorsed hereon shall unless
sooner revoked or ceasing to have effect under the provisions
of section 10 of the above-mentioned Act remain in force until
the 31st day of March next succeeding the date of issue or
renewal.
Dated this day of , 19 .
Registrar.

SECOND SCHEDULE.

Diethyl barbituric acid and other alkyl, aryl, or metallic
derivatives of barbituric acid, whether described as veronal,
proponal, medial, or by any other trade name, mark, or
designation; and all poisonous urethanes and ureides.
Dinitrophenols, dinitrocresols, and preparations or ad-
mixtures containing any such substances.
Chlorodyne and any preparation or admixture containing
one-tenth of one part per centum or more or morphine, not
being a dangerous drug within the meaning of the Dangerous
Drugs Act, 1927.

C. A. JEFFERY,
Clerk of the Executive Council.