Published on National Portal of India (india.gov.in) GOVERNMENT OF ARUNACHAL PRADESH DIRECTORATE OF HEALTH SERVICES (FORM 19) (See Rule 59 (2) ) Application for grant on renewal of a licence (to sell, stock, exhibit or offer for sale or distribution) of drugs other than those specified in Schedule X. I/1. hereby apply licence 2. The sale and dispensing of drugs will be made under the personal supervision of a qualified person, namely:- Name Qualification 3. Categories of drugs to be sold 4. 5. A fee of rupees Signature Date has been credited to Government under the head of account Cosmetics Rules, 1945 and also to operate a pharmacy on the premises situated at Name Qualification Particulars for special storage accommodation We APPLICATION FORM FOR DRUGS LICENCE whole sale/ retail drugs specified in Schedule C and C (1) excluding those specified in Schedule X and/or drugs other than those specified in Schedule C , C (1) and X to the Drugs and to sell by /-Rs. ( ) Published on National Portal of India (india.gov.in) I hereby undertake to serve under owner of the pharmacy in the name and style of M/S situated at for a period of Dated Place Signature of witness Signature of Pharmacist Address ToFrom UNDERTAKING I Shri son/ daughter/ wife of Shri resident of Village/Town P.O. District , am registered Pharmacist under council. My registration No. is (copy of the registration certificate enclosed). Shri/ Smt Published on National Portal of India (india.gov.in) Application in Form NO.-19(1) (Under Sub-Rule(2) of Rule 59 of D&C :Rules 1945 as 6th Amendment). Treasury Challan under the head of Account-"0210" Medical and Public Health as below- (U/R 59(2) (1) of D&C Rules 1945). (2) 1) 2) Category-II (Drugs by wholesale Specified in Schedule C&C (1) N.B.:- For both Categories of Drugs Licence Under taking/Affidavit of Registered Pharmacist or Matriculate(Passed Class-A) or its equivalent with four years experience, in dealing with drugs. (3) (4) Sketch map of the site of the proposed premises (area of the premises not less than ten square meters.) (5) Inspection report of the Drugs Inspector/Ex-Officio in Drugs Inspector.(6) (7) (8) S.T. Certificate of the applicant.(9) Category-I (Drugs by wholesale other than those (Specified in Schedule C&C (1) (Copy of the afore-said Certificate duly attested by Gazetted officer should be submitted). Constitution of the firm (documentary evidence in respect of the ownership,Rental or other basis of the premises, any other employee other the ownership etc) (U/R 65 (A) of D&C Rules 1945) Trading Licence/ Assurance Certificate from the competent authority of the respective District. Inner line permit of Pharmacist or I/C of the qualified person(in case of non Arunachalee.) Rs.1500/- Rs.1500/- Rs.3000/- (OTHER THAN THOSE INCLUDE IN SCHEDULE 'A') CRITERIA TO BE FULL FILL BY APPLICANT FOR GRANT/RENEWAL OF DRUGS LICENCE FOR WHOLE SALE LICENCE FOR RETAIL SALE
