Download Application for Grant/Renewal of Licence for Sale of Drugs by Retail or Wholesale

Special Form-A. Drugs Control Administration,. File Number:- Government of Tripura, Agartala. To, The Licensing Authority & Deputy Drugs Controller. Pandit Nehru Office Complex, Kunjaban, Agartala-799006. Subject :-Application for Grant/Renewal of licence for sale of drugs by Retail/ Wholesale/Motor Vehicle(strike out which ever is not applicable). Sir, I/We hereby furnish the following information/documents under rule-65-A of the Drugs & Cosmetics Rules-1945 for renewal of the licence under rule-64/62-B of the said rules:- I. Particulars of the applicant :- :- (a). Name in full :- (b).Fathers/Husbands Name :- ©.Residential address with Telephone No.,if any :- (d).Nationality :- (e).Name of the shop :- (f).Address of the shop :- (g).Constitution of the firms :-Sole proprietorship/ partnership/ pvt.ltd./ others/ (specify). (h).Basis of lawful ownership of occupation of the shop :- (i).Name of the lawful owner(landlord) :- of the shop premises. (j).Name,address, & licence No. :- of additional premises,if any. (k).Trade licence No. with date :- (to be issued by Agartala Municipal Council or Nagar Panchayat as the case may be). (l).Occupation,trade or business :- ordinarity carried out by the applicant during last three years. II. Particulars of the premises and storage accommodation :- (a).Type of construction of the premises :- Walls :- Floor :- Roof :- b).Name of rooms :- size:- Length:- Breath :- Height :- Total floor area of the premises :- Sq.m. (minimum requirement 10.sq.m.). (c).Storage accommodation(existing):- Glass door almiraha/rack: - No.-------- size---------------- Show case with glass protection No :-------- size---------------- Open racks: - No:--------- size--------------- Refrigerator No:----------- size--------------- Others,if any(specify) No:----------- size--------------- ©Option to maintain cash/credit memo:-Only cash memo/both cash memo & credit memo. III Particulars of sellers, competent person/Qualified person In-Charge. (use separate sheet if the space is not adequate). S.L.No. Name & address Date of engagement Educational qualification &Pharmacist Registration , if any. Whether orientation training attended.if so, S. L. No.& date. 1 2 3 4 5 1. 2. IV. Particulars of additional information to be furnished . Licence No-------&-------- in Form ----&----issued on----------and renewal upto------- (b).T.S.T.registration No---------------, date of issue----------- © C.S.T.registration No.---------------, date of issue------------ (d).Memo maintained :-only cash memo/cash&cradit memo/both. (e).Inspection Book :-maintained/not maintained/applied for on. V. List of documents enclosed :- (put tick mark to indicate compliance). (a). Form No. 19/19A/19AA dated-------------- (b).Original copy of the receipted Treasury Challan No------ dated------- for Rs.------ (c)Attested copy of the constitution of the firm, if it is not a sole proprietary one. (d)Attested copy of Tripura Sale Tex Clearance Certificate to be issued by Tripura sale Tax Authority. (e)Attested copy of Trade License issued by Agartala Municipal Council or Nagar Panchayet, if the shop falls under such areas. (f)A sketch showing location & layout & dimension of the premises you (It should indicate the places surrounding the shop, length & breath of the shop duly signed by the applicant).(g)Competent Person/Qualified Person/Seller:- (a)Attested copy of citizenship certificate,(b)educational qualification certificate.(c) pharmacist registration certificate with documents showing upto date renewal (only in case of registered pharmacist)(d) Experience Certificate in sale of drugs in respect of seller,competent person and qualified person In-Charge of the shop. (h). An attested copy of Motor Vehicle Registration number with ownership documents (for Motor Vehicle only). (i).Consent to work as qualified person/competent person. An undertaking of qualified person/competent person shall be made in Non-Judicial Stamp Paper of not less that Rs.10.00(ten) as per enclosed specimen. (j). Ownership of occupation documents: - (i) Rental document or otherwise :- An attested/certify copy of Registered Deed of agreement in case of rental or other basis of occupation of the premises for a period of 05(five) years along with a attested copy of Khatian of the plot of land. (ii).An attested copy of Registered Deed of purchase of the property/Khatian showing ownership of the land/premises, if it is an ownership one. (k). An attested copy of purchase documents of Refrigerator (if provided). (l). Attested copy of documents showing appearence of evaluation test after the orientation training for qualified person/ competent person in-charge 2.I do hereby state that above information and documents furnished by me are true to my knowledge and belief. I also state that I shall abide by the provisions of the Drugs & Cosmetics 1940 & Rules there-under and instruction issued by the Authority from time to time. 3.I shall have no cause of action, if any action is taken by the Licensing Authority, in case of detection of incorrect/false information/documents produced as above by me. Enclose :--------( )sheets. Yours faithfully, Dated----------- (Full signature of the applicant). N:B: Strike out whichever is not applicable. Read the instruction sheet carefully before fill in the application. Government of Tripura Office of the Deputy Drugs Controller. Agartala The Drugs and Cosmetics Rules,1945. FORM--19. (See Rule-59(2) ). Application for grant or renewal of a licence to sell, stock, exhibit or offer for sale or distribute drugs other than those specified in schedule-X. 1. I/We-----------------------------------------------------------------------------------------hereby apply for licence to sell be wholesale/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, and C (1) and X to the Drugs & Cosmetics Rules,1945 and also to operate a pharmacy on the premises situated at------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 2. The sale and dispensing of drugs will be made under the personal supervision of the qualified persons namely: - Name--------------------------------------Qualification----------------------------------------Name --------------------------------------Qualification--------------------------------------- 3. Categories of the drugs to be sold ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ***4. Particulars for special storage accommodation: ------------------------------------- 5. A fee of rupees -------------------------- has been credited to the Government Accpunt under the Head of Account "0210-Medical & Public Health" vide challan No.---------- dated----------------------- Date : -------------------------- (Signature of the applicant). Delete whichever is not applicable. ** To be deleted if drugs will be sold only by wholesale. *** Required only if products requiring special storage are to be sold. &&&&&&&&&&&&&& Government of Tripura Office of the Deputy Drugs Controller. Agartala The Drugs and Cosmetics Rules,1945. FORM 19AA. (See Rule-62(C) . Application for grant or renewal of a (licence to sell, stock, exhibit or offer for sale by wholesale or distribute)drugs from a Motor Vehicle. 1. I/We---------------------------------------------------------------------------------------------of-----------------------------------------------------------------------------------hereby apply for licence to sell stock, exhibit or offer for sale by wholesale or distribute drugs specified in schedule C and C(1) and or drugs other than those specified in schedule C and schedule C(1) from the vehicle bearing registration Number--------------------assigned under the motor vehicle Act 1939. 2. Categories of drugs to be sold/distributed. --------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- 3. A fee of rupees------------------ has been credited to Government under the Head of Account "0210 Medical and Publis Health" vide challan No.------------------ dated--------------------. 4. Particulars of the storage accommodation for the storage of drugs specified in schedules C and C(1) drugs on the vehicle reffered to above.premises refered to above Date : -------------------------- (Signature of the applicant). Government of Tripura Office of the Deputy Drugs Controller. Agartala The Drugs and Cosmetics Rules,1945. FORM 19A. (See Rule-59(2) ). Application for grant or renewal of restricted licence to sell, stock, exhibit or offer for sale or distribute drugs by retail dealers who do not engage the service of qualified person. 1.I/We---------------------------------------------------------------------------------------------of-----------------------------------------------------------------------------------hereby apply for licence to sell by retail(i) drugs other than those specified in schedule C, and C (1) and X or (ii).drugs specified in schedule C(1) on the premises situated at-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 2.Sales shall be registered to such drugs as can be sold without the supervision of a qualified person under the Drugs & Cosmetics Rules. Name-----------------------------------------------------Qualification-------------------------Name-----------------------------------------------------Qualification------------------------- 3. Particulars of the storage accommodation for the storage of schedules C(1) drugs on the premises refered to above ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 4.The drugs for sale will be purchased from the following dealers such other dealers may be endorsed on the licence by the Licensing Authority from time to time. 5.A fee of rupees -------------------------- has been credited to the Government Accpunt under the Head of Account "0210-Medical & Public Health" vide challan No.---------- dated-------------------- Date : -------------------------- (Signature of the applicant). &&&&&&&&&&&&&& SPECIMEN OF UNDERTAKING OF REGISTERED PHARMACIST/ COMPETENT PERSON. (To be made in Non-Judicial Stamp Paper) To, The Deputy Drugs Controller, Government of Tripura, Agartala. Subject :- Undertaking on performance of duties as Registered Pharmacist/ Competent Person In-Charge. Sir, I hereby state that I have agreed to work as Registered Pharmacist/Competent Person In-Charge on full time basis in the premises of Shri/Smti------------------------------- premises situated at----------------------------------------------------------,for period of at least 03(three) years from the date of renewal of the license or from the date approval or till the date of next renewal. Particulars of myself are given below: - 1. Name : - 2. Fathers/Husbands Name : - 3. Permanent address : - 4. Present address : - 5. Educational Qualification : - With year of passing (attested copy enclosed) 6. Pharmacist Registration No. : - with period up to which valid (in case of Registered Pharmacist) (attested copy enclosed). 7. Date of birth (attested copy of documents enclosed) :- 8 Name of establishment in which worked after getting Pharmacist Registration /Educational Qualification as Qualified Person/ Competent Person (attested copy of Certificate from the establishment are enclosed):- (a)___________________ From______________ to ____________________ (b)________________________From_______________ to __________________ (9). Other profession/business/trade/calling carried out other than that of qualified person/ competent person as mentioned in columns No. 8 above during last 03(three) years are given below. (a) ________ ______________ Form _________________ to __________________ _______________________Form__________________ to __________________ II. I am aware of the duties and responsibilities of Registered Pharmacist/Competent person. I shall perform my duties in accordance with the provisions of the Drugs & cosmetics Act & Rules there-under and maintain code of conduct & ethics. I shall use my full signature on the cash memos or credit memos as given below and I shall be held responsible, if any drug is sold without issue of memo. III. I further declare that I am not working at any other place or carrying out any other Profession at present. IV. If I am unable to discharge my duties I shall be duty bound to report to the Licensing Authority as well as to the concerned Inspecting Officer (Drugs). V. I shall also ensure that the shop remain open for sale only in my presence. I shall have no cause of action, if any action including disqualification for future performance of duties is taken against me by the Authority, in case of my failure to abide by the above. Date :- Signature in full of the Registered Pharmacist/Competent Person In-Charge. INSTRUCTION TO APPLICANT. 1.The application Form-A and 19/19A/19AA shall be carefully and properly filled up to avoid delay in processing Challans may be got certified by the Inspecting Officer (Drugs) on production of copy of last renewal certificate and licences.Separate application shall be made for separate premises. 2.Strike out the word/words which is/are not applicable. 3. Minimum space (floor area) required for retail wholesale business is 10(ten) sq. metres as per the Drugs & Cosmetics Rules-1945, which is not relaxable. 4. Every shop shall have at least one full time Registered Pharmacist/Competent Person. Qualification and Experience required for a qualified person/competent person as per the said Rules are given below . Qualified Person In-Charge for Retail sale :-A Pharmacist registered by the Tripura State Pharmacy Council. Competent Person In-Charge for whole sale and motor vehicle:- (i) A Registered Pharmacist under the Tripura State Pharmacy Council or (ii)a matriculate with 04(four) years experience in selling drugs or (iii)a graduate with 01(one) year experience is selling drugs. Person processing the above mentioned qualification & experience will be required to attend an Orientation Training Programme followed by an evalution test conducted by the Licensing Authority for approval as qualified/Competent person In-Charge. Orientation Training Programme commences from Wednesday to Friday of the week after the 2nd Saturday of every month. However the exact dates should be confirmed from the office over Telephone number-2325868. 5. All the documents submitted should bear the full signature of the applicant as proof of submission 6.In case of renewal no document is necessary, if the documents submitted earlier are still in force or valid, and a statement to that effect is submitted alongwith the renewal application. 7.A separate sheets may be enclosed, if the space provided is found inadequate in any item. 8.Application for renewal alongwith all documents should reach the office within the validity. Application for renewal may be submitted within 06(six) months after the expiry of validity with additional fee per licence per month of part thereof.However no business shall be carried out by such person after the expiry of validity.Licences shall be deemed to have expired under rule 63, if no application is received within 06(six) months of the expiry of the validity. 9.Licensee shall maintain an Inspection Book in the shop. 10.No drugs shall be sold without issue of cash memo or credit memo which shall bear full signature of the Registered Pharmacist/Competent Person/ seller as the case may be Option to maintain credit memo shall be conveyed in writing to the Licensing Authority and permission taken thereof. 11.No Registered Medical Practioner (RMP) is allowed to treat patient in the licensed premises. 12.Carbon copies of cash memo/credit memo shall bear all the particulars of the original copy and shall be legible. Serial number shall be in chronological order & printed. 13.A sign. board shall be displaced at the licensed premises. 14.This instruction should not be sent to the office alongwith application. 15.Fees deposited are not refundable even if the licence are not renewed. Application fees payable for retail licence --Rs. 3000/-(In Form 20 & 21). Application fees payable for retail(restricted)licence - Rs. 1000/-(In Form 20A &21A). Application fees payable for wholesale licence Rs. 3000/-(In Form 20B & 21B) Application fees payable for of Motor Vehicle licence Rs. 3000/-(In Form 20BB & 21BB). Additional fee for retail/wholesale/Vehicle licence:Rs.1000/-per month or part there of for two licence). Additional fee for restricted licence :-Rs.500/-per month or part thereof(for two licence). 16.Any clarification, if required, may be had from the Inspecting Officer (Drugs) of the concerned area. Deputy Drugs Controller. Government of Tripura,Agartala. CHALLAN ( TO BE FILLED BY THE TENDERER ) On whose behalf the money is paid:------------------------------------------------------------- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Particulars of the remittance:- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Amount Rs. (Rupees ) only. Signature of the Tenderer - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ( TO BE FILLED BY THE DEPARTMENTAL OFFICER ) No. Date:- Treasury Code D.D.O. Code T P A 0 8 Major Head Sub-Major Head Minor Head Sub- Minor Head 0 2 1 0 0 6 1 0 4 ORDER TO THE BANK: CORRECT, RECEIVED AND GRANT RECEIPT. Signature of the officer ordering The money to be paid in - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ( FOR USE IN BANK ) Received payment for Rs. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( Cashier/Head Clerk ) ( Accountant ) ( Branch Manager )