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OnBoard Drugs Sale Licence Application
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
In case of Partnership Firm
Sno
Salutation
Name of Partner
Father's/Husband's Name
Address
Mobile
Landline No.
Email Id
ID Card
ID Card No.
1.
---
Mr.
Mrs.
Ku.
-Select-
Driving Licence
Passport
Voter ID Card
PAN Card
Ration Card
Others
In case of Director (as on date)
Sno
Salutation
Name of Director
Father's/Husband's Name
Address
Mobile
Landline No.
Email Id
ID Card
ID Card No.
1.
---
Mr.
Mrs.
Ku.
-Select-
Driving Licence
Passport
Voter ID Card
PAN Card
Ration Card
Others
In case of Others
Sno
Salutation
Name
Father's/Husband's Name
Address
Mobile
Landline No.
Email Id
ID Card
ID Card No.
1.
---
Mr.
Mrs.
Ku.
-Select-
Driving Licence
Passport
Voter ID Card
PAN Card
Ration Card
Others
Competent Person Details (if registered Pharmacist 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.
---
Mr.
Mrs.
Ku.
-Select-
Driving Licence
Passport
Voter ID Card
PAN Card
Ration Card
Others
And / OR
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.
---
Mr.
Mrs.
Ku.
-Select-
B.Pharm
D.Pharm
Others
-Select-
Driving Licence
Passport
Voter ID Card
PAN Card
Ration Card
Others
Y
N
Name of Drugs to be Sold
*
Drug Product/ Drug Substance of Oseltamair
Drug Product/ Drug Substance of Ketamine
Any Other Drug Product/Drug Substance
Description
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.