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APPLICATION FORM FOR APPROVAL OF PHARMACY/ CHEMIST / DRUGGIST
SHOPS / MEDICAL STORE AS TRAINING CENTRE FOR [Link] STUDENTS
o:
a
e
4.
‘Name of Pharmacy/ Chemist/Druggist Shop:
Medical store
Govt Pvt,
(Please tick the relevant)
Complete postal address
Pin code
Details of Owner
Name of the Owner
Complete Residential Address
Pin code
Telephone No. STD Code Landline
Mobile No.
EMail
Whether the Pharmacy /Chemist/Druggist Shops! Yes No
Medical Store is approved under Drug &
Cosmetics Rules, 1945 framed under
Drug & Cosmetics Rules, 1940 (if yes,
attach the copy of license with date of validity)
Date of Validity
of license
(Please tick the relevant) 8.
Details of Registered Pharmacist working (in Nos.
{attach the copy of Qualification Certificate and Pharmacist Registration Certificate of each
Pharmacist)
‘Name Gender | Mobile No. Signatare
Our of
Pharmacist
(attach a copy of|
certificate) | valid registration
certificate)
6. — Whether the name of Owner is displayed on Pharmacy:
Yes No
Declaration:
Thereby declare that all statements made in the application are true, complete and correct to
the best of my knowledge and belief.
| will impart training to only students of those Institutions/Colleges/University instt
are approved under section 12 of the Pharmacy Act, 1948.
It is also certified that during the course of the practical trai
fan exposure to -
ing, the trainee will be given
i, Working knowledge of keeping of records required by various Acts concerning the
profession of Pharmacy, and ii, Practical experience in -
a. the manipulation of pharmaceutical appartus in common use
the reading, translation and copying of prescription including checking of doses;
c. the dispensing of prescription illustrating the commoner methods of administering
‘medicaments; and
d._ the storage of drugs and medical preparations.
4, Tunderstand that in the event of any information being found untrue / false / incorrect this
application will be cancelled rejected, without assigning any reasons thereof.
Date
Place
(Signature of Owner/Applicant)
Name of Owner:
‘Mobile No:
Forwarded by State PI
mat to PCI (Office use only,
Name of the Registrar
Name and address of State Pharmacy Council
Date: Signature :