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New Drugs Sale Licence Application
Application Details
Drug Licence Type*    
Constitution of Shop/Firm*  
Name of Shop/Firm* Status of Premises*
Shop No./Plot No. *
Shop/Firm's Colony* Shop/Firm's Locality/ Village *
District* Tehsil *
Pincode * Area of Premises*    (Sq. Fts)
0    (Sq. Meters)
Applicant Personal Details
Applicant First Name* Applicant Last Name *
Father's/Husband's First Name* Father's/Husband's Last Name*
Date of Birth Mobile Number*
Email ID Experience   (if any in Drug Trade)
Business/Occupation of Applicant in past 3 years *

Local Address of Applicant

House No. * Colony
District* Area/ Village *
Tehsil * Pincode*
Are Local address and Permanent Address same?

Permanent Address of Applicant

House No. * Colony
District* Area/ Village *
Tehsil * Pincode*
Applicant Qualification
Qualification Passing Year Marks Obtained Total Marks University/Board
Competent Person Details (if Applicant and Competent person are different)
Sno Salutation Name Father's/Husband's Name Date of Birth Experience Qualification University/Board ID Card ID Card No.
1.
Registered Pharmacist(s) Details
Sno Salutation Name Father's/Husband's Name Address Date of Birth Registration No. Registration Date Registration
valid upto
Qualification ID Card ID Card No. whether applied for further Renewal? University
1.


Declaration
I   hereby declare that all the details furnished in the form are valid and correct, in case any detail found to be incorrect/ invalid, I will be responsible and the Licensing Authority has the right to reject this application. I understand that In case of rejection, fee would not be refunded under any circumstances.
 I  hereby undertake to comply with all the provisions of THE DRUGS AND COSMETICS ACT, 1940 AND RULES, 1945 as applicable to me.