Application Details

Drug Licence Type *	-Select- Retail Sales Drug Licence Restricted Licence Whole Sales Drug Licence Retail and Whole Sales Drug Licence Restricted and Whole Sales Drug Licence
Form 20 Licence Number* Form 20 Issue Date Form 20 validity upto* Form 21 Licence Number* Form 21 Issue Date Form 21 validity upto* Form 20-A Licence Number* Form 20-A Issue Date Form 20-A validity upto* Form 21-A Licence Number* Form 21-A Issue Date Form 21-A validity upto* Form 20-B Licence Number* Form 20-B Issue Date Form 20-B validity upto* Form 21-B Licence Number* Form 21-B Issue Date Form 21-B validity upto* Form 20-F Licence Number* Form 20-F Issue Date Form 20-F validity upto* Form 20-G Licence Number* Form 20-G Issue Date Form 20-G validity upto*
Constitution of Shop/Firm*	-Select- Proprietor Partnership Firm Private Limited Public Limited Limited Firm Co-operative Institution Society Trust Others	Specify Other*
Registration No. of Shop/Firm
Name of Shop/Firm*		Status of Premises*	-Select- Rented Lease Self Owned Others
Shop No./Plot No. *		Specify Other Premises
Shop/Firm Colony*		Shop/Firm Locality/ Village *
District*	-Select- AGAR ALIRAJPUR ANUPPUR ASHOK NAGAR BADWANI BALAGHAT BETUL BHIND BHOPAL BURHANPUR CHHATARPUR CHHINDWARA DAMOH DATIA DEWAS DHAR DINDORI GUNA GWALIOR HARDA INDORE JABALPUR JHABUA KATNI KHANDWA KHARGONE MANDLA MANDSOUR MORENA NARMADAPURAM NARSINGHPUR NEEMUCH NIWARI PANNA RAISEN RAJGARH RATLAM REWA SAGAR SATNA SEHORE SEONI SHAHDOL SHAJAPUR SHEOPUR SHIVPURI SIDHI SINGRAULI TIKAMGARH UJJAIN UMARIA VIDISHA	Tehsil *
Pincode *		Area of Premises*	(Sq. Fts) 0    (Sq. Meters)
ID proof of Licensee*	-Select- Driving Licence Passport Voter ID Card PAN Card Ration Card Others	ID Number*
Specify other document

Applicant Personal Details

Applicant First Name*	--- Mr. Mrs. Ku.	Applicant Last Name *
Father's/Husband's First Name*		Father's/Husband's Last Name*
Date of Birth		Mobile Number*
Email ID
Business/Occupation of Applicant in past 3 years *	NA
Local Address of Applicant
House No. *		Colony
District*	-Select- AGAR ALIRAJPUR ANUPPUR ASHOK NAGAR BADWANI BALAGHAT BETUL BHIND BHOPAL BURHANPUR CHHATARPUR CHHINDWARA DAMOH DATIA DEWAS DHAR DINDORI GUNA GWALIOR HARDA INDORE JABALPUR JHABUA KATNI KHANDWA KHARGONE MANDLA MANDSOUR MORENA NARMADAPURAM NARSINGHPUR NEEMUCH NIWARI PANNA RAISEN RAJGARH RATLAM REWA SAGAR SATNA SEHORE SEONI SHAHDOL SHAJAPUR SHEOPUR SHIVPURI SIDHI SINGRAULI TIKAMGARH UJJAIN UMARIA VIDISHA	Area/ Village *
Tehsil *		Pincode*
Are Local address and Permanent Address same?
Permanent Address of Applicant
House No. *		Colony
District*	-Select- AGAR ALIRAJPUR ANUPPUR ASHOK NAGAR BADWANI BALAGHAT BETUL BHIND BHOPAL BURHANPUR CHHATARPUR CHHINDWARA DAMOH DATIA DEWAS DHAR DINDORI GUNA GWALIOR HARDA INDORE JABALPUR JHABUA KATNI KHANDWA KHARGONE MANDLA MANDSOUR MORENA NARMADAPURAM NARSINGHPUR NEEMUCH NIWARI PANNA RAISEN RAJGARH RATLAM REWA SAGAR SATNA SEHORE SEONI SHAHDOL SHAJAPUR SHEOPUR SHIVPURI SIDHI SINGRAULI TIKAMGARH UJJAIN UMARIA VIDISHA	Area/ Village *
Tehsil *		Pincode*

Applicant Qualification

Qualification	Passing Year	Marks Obtained	Total Marks	University/Board

And / OR

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.