1964_PHARMACY_AND_POISONS_REGULATIONS — Page 71

1987 Ed.]

Pharmacy and Poisons Regulations

[CAP. 138

A 71

[Subsidiary]

FORM 8

[reg. 41(1).]

表格八

〔規例第四一條第(一)款〕

PHARMACY AND POISONS ORDINANCE 藥劑及毒藥條例

(Chapter 138)

(香港法例第138章)

CERTIFICATE

證明書

For the purposes of section 22(1)(a) of the Pharmacy and Poisons Ordinance,

根據藥劑及毒藥條例第二二條第(一)款(甲)段之規定,

I, the undersigned, occupying (a)

本人,即下開簽署人,地址為(甲)

hereby certify that I am acquainted with (b),

茲證明本人熟悉(乙)

and with (c).

及(丙)

and that (b)

而(乙)

is a fit and proper person to whom

係適宜獲得

(d)

(丁)

be supplied by (c)

供應人為(丙)

I further certify that (e)

茲證明此簽名:(戊)

之簽名。

(Name in block letters)

(以正楷填寫姓名)

(a) Insert full postal address.

(甲) 填寫詳細郵寄地址,

Date

日期:

(b) Insert full name of intending purchaser.

(乙) 填寫有意購買者之全名。

(c) Insert full name of intending seller.

(丙) 填寫有意售賣者之全名。

(d) Insert name of poison.

(丁) 填寫毒藥名稱。

(e) Intending purchaser to sign here.

(戊) 有意購買者在此簽署。

is the signature of the said (b).

係上述(乙)

may properly

之供應,

Signature of person giving certificate.

發給證明書者簽署