BIO-DATA of Applicant(s)
1. Name of the applicant :
2. Age, Date of Birth :
3. Son of / Daughter of :
4. Residential Address :
5. Permanent Address with [Link] :
6. School at which studied
Name & Address of the school Class studied Period Studied
7. College at which studied
Name & Address of the College Course studied Period Studied
8. Professional Experience
Name & Address of the institution where Period Post held Reasons for Leaving
served
9. Whether the applicant ever holding the drug license? If so details
10. Whether the applicant family members ever holding the drugs licences? If so details
11. Specimen Signature
1.
2.
3.
The details above furnished are true to the best of my knowledge
Place:
Date: ` Signature of applicant
BIO-DATA of Qualified/Competent Person
1. Name of the Qualified person(s) :
2. Age, Date of Birth :
3. Son of / Daughter of :
4. Residential Address :
5. Permanent Address with [Link] :
6. School at which studied
Name & Address of the school Class studied Period Studied
7. College at which studied
Name & Address of the College Course studied Period Studied
8. Professional Experience
Name & Address of the institution where Period Post held Reasons for Leaving
served
9. Whether the applicant ever holding the drug license? If so details
10. Whether the applicant family members ever holding the drugs licences? If so details
11. Specimen Signature
1.
2.
3.
The details above furnished are true to the best of my knowledge
Place:
Date: ` Signature of Qualified/Competent Person
DECLARATION FORM
(This must be filled in and returned to the Assitant Director of Drugs Control along
with application form)
(Note: No column should be left blank or with a dash. If you have no particulars to
furnish for any application is made, “Nil” Does not arise should be entered)
1. Name and Complete address of the firm
for which application is made
2. Name(s) and residential address(es) of the
Proprietor/all Partners/all Directors/Managers
3. Applicant’s previous occupation
4. Applicant’s present occupation
5. Applicant’s experience ,if any in drug trade `
6. Is the application for fresh license or renewal
7. Was there is any change in the Proprietorship/
Partnership of the concern since the issue of
Previous licensees and if so, from what date?
(A true copy of the sale deed should be sent)
8. Was there any change in the premises of the
concern since the issue of previous licenses
and if so, from what date?
9. Particulars of licenses held by the applicant
In respect of the premises for which the present
application is made under Drugs & Cosmetics Act
Form Licence. No Date of Issue
20/21
20A/21A
20B/21B
20C/21D
10. Addresses of the premises where the Drugs are stocked
or sold or office is maintained by the applicant. The Drugs
licenses number, form of license and date of issue of each
license pertaining to the above should be stated,
11. What category the firm come under
a. General Merchant
b. Chemist and Druggists
c. Pharmacy
d. Wholesale Dealer (Mention the name of the company)
e. Importers (Mention the name of the country,
Drugs to be imported)
f. Distributing Agency( state the name of the manufactures
for whom you are the distributor or agency and furnish
a true copy of the agreement)
12. Is there a separate cupboard or drawer reserved solely
for the storage of schedule X drugs?
13. Nature of cold storage provided
(Mention the company & capacity)
Whether it is in working condition
14. If running a pharmacy whether the requirements of Schedule "N"
To the Drugs Rules have been provided (A list of equipment and
books available should be enclosed)
15. Particulars of qualified person(s) employed Name
Cert/[Link] Validity
16. Hours of business and working days
17. Have you ever convicted under the drug act or any other act?
18. Was the application ever rejected / cancelled/
suspended /surrendered previously?
19. Are you the legal tenant of the premises occupied by you?
I declare that the above statements are true. I further declare that I am conversant with the
provisions of the Drugs Act, 1940 and the drugs rule, 1945 and I will abide by the conditions
of the licences.
Station:
Date: Signature of the applicant
Declaration of the Pharmacist(S) or Competent Person
I /We hereby declare that I /We /am/are employed in the above firm as full time qualified person(s) and not
employed anywhere else and submit the details of the previous employments.
[Link] Name [Link] Residential Previously employed at
address __________from______to____
Station:
Date: Signature of the qualified person(s)