568  PROPOSED  LAW  REGULATING  PHARMACY,  ETC. 
SCHEDULE  D. 
Declaration  hy  a  person  applying  to  become  Registered  Assistant  in  Pharmacy. 
I,  of  hereby  declare,  that  I  am  a  graduate  of  the 
College  of  Pharmacy,.  Class  18  ;  or  am  a  graduate  of  the  [foreign 
institution,  date.]  my  diploma  having  been  acknowledged  and  endorsed  by 
the  Pharmaceutical  Board  of  the  State  of  on  the  [date]  ;  or  am  a 
practising  assistant  in  pharmacy,  holding  a  certificate  of  qualification  by  the 
Pharmaceutical  Board  of  this  State,  dated  ;  and  apply  to  be  entered 
as  registered  assistant  in  pharmacy. 
(Signed)  Name, 
Dated  this  day  of  ,  18 
Affidavit. 
SCHEDUDE  E. 
Certificate  of  qualification  to  he  issued  by  the  Pharmaceutical  Board  to  practising 
Assistants  in  Pharmacy. 
This  certifies  that  of  County  of  State 
of  ,  has  produced  satisfactory  evidence  to  the  Pharmaceutical 
Board  of  the  State  of  of  having  served  not  less  than  four  years  as 
an  apprentice  in  a  shop  or  shops  where  the  prescriptions  of  medical  practi- 
tioners were  dispensed;  has  been  properly  examined  by  this  Board,  (appointed 
by  the  Governor,  in  conformity  with  Section  5  of  the  Pharmacy  and  Poison 
Act,  18  )  and  on  ballot,  after  such  examination  is  declared,  by  a  proper  vote 
of  this  Board,  to  be  competent  to  dispense  poisons  and  compound  medicines, 
subject  to  all  legal  restrictions.  In  testimony  whereof  the  Officers  of  this 
Board  have  hereunto  signed  their  names  this  day  of  18 
SCHEDULE  F. 
Form  in  which  registered  pharmacists  and  retail  dealers  in  poisons  shall  keep  their 
poison-book. 
Date. 
Name  of  Pur- 
chaser. 
Name  and  quantity 
of  poison  sold. 
For  what  purpose 
said  to  be  required. 
Remarks. 
SCHEDULE  G. 
Form  of  license  to  be  issued  to  retailers  of  poisons  in  rural  diHricts. 
Ij  ,  Registrar  of  Pharmacists,  at  the  written  request  of 
of  ,  County  of  ,  State  of  ,  and  upon  his 
written  declaration  that  no  registered  pharmacist  is  situate  within  three  miles 
of  bis  place  of  business,  have,  in  accordance  with  the  provisions  of  Section  8 
of  the  Pharmacy  and  Poison  Act,  18  ,  and  upon  payment  by  him  of  one 
dollar,  do  hereby  issue  to  him  this  license,  authorizing  him  to  retail  poisons 
•uuder'the  restrictions  provided  in  said  Act. 
(Signed)  Name, 
\  SEAL  \  Registrar  of  Pharmacists 
J  "  Of  the  State  of 
Office  No.  Street, 
Town, 
County. 
Dated  this  day  of  ,  18 
