APPLICATION FOR LICENCE FOR RETAIL AND WHOLESALE DRUG LICENCE

Application Processing Location

Service Apply To: *

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Application would be processed according to the office choosen above **

Application Type and Ownership Details

Application Type(P) *

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Wholesale

Retail

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Type of Ownership *

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Proprietary

Partnership

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1.Name of Proprietary *

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1.Photo of Proprietary(Size should be in between 50-250kb) *

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1.Name of Partners *

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1.Photo of Partner(Size should be in between 50-250kb) *

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2.Name of Partners *

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2.Photo of Partner(Size should be in between 20-150kb) *

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3.Name of Partners

3.Photo of Partner(Size should be in between 50-250kb)

4.Name of Partners

4.Photo of Partner(Size should be in between 50-250kb)

5.Name of Partners

5.Photo of Partner(Size should be in between 50-250kb)

Applicant Details

Mobile Number *

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Name of Enterprise *

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Address of the Applicant *

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E-Mail *

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Address of the Premise *

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Drugs Categories(P) *

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Specified in Schedules C and C(1)

Specified in Schedule X

Other than those specified in Schedule C, C(I) and X

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Name of the Competent Person / Pharmacist

Please select the following option *

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Competent Person

Pharmacist

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1.Please Upload Photographs(Size should be in between 50-250kb) *

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1.Name of the Pharmacist/Competent Person *

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2.Registration No *

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3.Valid up to date *

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Name of Pharmacist

(i).Name(s) Pharmacist *

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(i).Registration No *

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(i).Valid up to date *

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1.Photographs of Pharmacists (Size should be in between 50-250kb) *

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(ii).Name(s) Pharmacist

(ii).Registration No

(ii).Valid up to date

2.Photographs of Pharmacists (Size should be in between 50-250kb)

(iii).Name(s) Pharmacist

(iii).Registration No

(iii).Valid up to date

3.Photographs of Pharmacists (Size should be in between 50-250kb)

(iv).Name(s) Pharmacist

(iv).Registration No

(iv).Valid up to date

4.Photographs of Pharmacists (Size should be in between 50-250kb)

Validity of Documents Submitted

Up to date Trading License(TNT)

1.Valid up to date

Up to date permission from Municipallity/Contt.Board/Local Dorbar

2.Valid up to date *

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3.Particulars of cold storage *

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Fees to be paid by Applicant

Total Amount to be Paid

Declaration

I hereby declare that all the particulars furnished in this application are correct to the best of my knowledge. I shall be held responsible for any incorrect information.

I Agree *