GOVERNMENT OF MEGHALAYA

APPLICATION FOR AUTO RENEWAL LICENCE FOR RETAIL AND WHOLESALE DRUG LICENCE

Type of Application

Choose Type of Application *

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Wholesale

Retails

Manufacturing

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Applicant Details

1.Name of the Licensee(Proprietor) *

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Photograph of proprietor(Size should be in between 50-250kb) *

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2.Name and Style of the Premises *

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2(a).Mobile Number *

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2(b).E-Mail *

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3.Address of the Premises *

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3(a)District *

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4(a).License No *

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4(b).Issue Date *

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4(c).License/Retention Retained upto date *

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4(d).Choose the certificate to be retained for Wholesale *

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20B

21B

20G

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4(d).Choose the certificate to be retained for Retailer *

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20

21

20F

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5.Period applied to retain: FROM *

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TO *

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Name of Pharmacist

6(i).Name(s) Pharmacist *

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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)

Name of the proprietor/Competent authority

Please select the following option

Proprietor

Competent authority

Pharmacist

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

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6.Name of the proprietor/Competent authority *

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6.Name of Pharmacist *

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Registration No. *

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Valid up to date *

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Validity of Documents Submitted

Up to date Trading License(TNT) *

Valid up to date *

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

Valid up to date *

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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 *