Form 19-A
[see rule 59(2)]
Application for grant or renewal of a restricted licence to sell, stock, exhibit
[or offer for] sale, or distribute drugs by retail by dealers who do not engage
the services of a qualified person
hereby apply for a licence to sell by retail (i) Drugs other than those specified
in Schedules C,C (1) and X on the premises situated at
(ii) Drugs specified in Schedule C(1 ) on the premises situated at
Drugs specified in Schedule C(1) as vender in the area
_______________________________________________
2. Sales shall be restricted to such drugs as can be sold without the supervision
of a qualified person under the Drugs and Cosmetics Rules.
3. Names or classes of drugs proposed to be sold
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4.*** Particulars of the storage accommodation for the storage of Schedule C(1)
drugs on the premises referred to above.
5.**** The drugs for sale will be purchased from the following dealers and such
other dealers as may be endorsed on the licence by the Licensing Authority from
time to time.
Name of Dealers________________________
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Licence No.
Licence No.________________________
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6. A fee of Rupees
has been credited to Government under the head of account 0210 Medical and Public
Health, 04 Public Health, 104 Fees and Fines, (5) Lic. Fees under Drugs and cosmetics
Rules. vide treasury receipt attached.
* Please mention the name (including father's/Husband's name, residential address
and Telephone number if any.
* * Please mention the name of the shop.
* * * Delete if not required.
* * * * Applies only to an itinerant vendor.
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