DECLARATION BY REGISTERED PHARMACIST / QUALIFIED PERSON with DRUGS INSPECTOR'S ENDORSEMENT I, ........ . . . . . . . . . . Son / Daughter of . . . . . . . . . . . . . . . . Presently residing at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . am a Registered Pharmacist / Qualified Person ( Regd. No. & Date . . . . . . . . . . . . . . . . . . . . renewed up to . . . . . . . . . . . . .) and submitting herewith an attested photocopy of the same renewed up to date. I am the Proprietor / Partner /Director/ Employee of M/s .... .... ... ... . . .. .. situa ted at D.N o. Place : Mandal; Dist; with effect from the date of this declaration. I hereby undertake to supervise the Sales of all the Drugs in the above sale premises and held my self responsible for the maintenance of all the Registers and Records ; cas h / credit memos as required under the Drugs and Cosmetics Rules 1945. If I want to leave from the services of the above shop, I will intimate my resignation to the Licencing authority ; concerned Drugs Inspector and to the management of the shop before more than one month in advance. My name was previously included in the Drugs licences in Form 20 ; 21 of M/s .......... D.NO. . . . ...Place ....Mandal .....Dist;....... Until .. I had tendered my resignation to the firm with effect from ..... and intimated the same to the Licencing authority vide my letter dated .... and a copy of the same is enclosed. I worked as Registered Pharmacist / Qualified person since .. (Last ten years) in the following sales firms. Date of Joining Name and Address of the firm Date of leaving Place: SIGNATURE Date : ENDORSEMENT OF THE DRUGS INSPECTOR The name of the above Registered Pharmacist / Qualified Person is not included in any Drug Licences in my Jurisdiction / Zone and original R.P.Certificate is kept in this office custody Place: Date: SIGNATURE OF DRUGS INSPECTOR WITH STAMP
