Download Application for Renewal of Licences for Retail/Wholesale of Drugs (HOMOEOPATHIC) Medicines

Special Form-B. Drugs Control Administration,. File Number:- Government of Tripura,Agartala. HOMOEOPATHIC. To, The Licensing Authority & Deputy Drugs Controller. Pandit Nehru Office Complex, Kunjaban, Agartala-799006. Subject : -Application for Renewal of licences for Retail/Wholesale of drugs (HOMOEOPATHIC)Medicines. Sir, I /We hereby furnish the following information and documents for renewal of licence for sale of drugs(Homoeopathics) Medicines. 1. PARTICULARS OF THE APPLICANT :- (a). Name of the applicant :- (b).S/O,/D/O,/W/O, :- ©.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/Co-Operative Society Ltd. (h).Basis of lawful ownership of occupation of the proposed shop :-Own/Rental/Others. (i).Name of the lawful owner(landlord) :- of the shop premises. (l) Trade Licence No with date(to be issued by Agartala Municipal Council/Nagar Panchyat. II.INFORMATION OF LICENCES(FOR RENEWAL ONLY) :- (a).Licence Number--------------------- in Form No.----------------Valid------------------ (b).Licence Number----------------- in Form No.------------------Valid------------------- ( c).Whether Inspection ook is maintained :- Yes/ No./applied for on (d). The T.S.T & C.S.T. Registration No.,if any :- III. PARTICULARS OF THE PREMISES :- (a). Type of construction Wall :- Floor :- Roof :------- (b). Number of rooms:- Size:- Length--------Breath--------------Height------- 4. PARTICULARS OF THE COMPETENT PERSON/SELLERS:- Name with address. Educational Qualification Period of Experience. 5. STORAGE ACCOMMODATION :- Number of glass door Almirahas. Number of other storage accommodation. 6. LIST OF DOCUMENTS ENCLOSED: - (a). Application Form-19-B.dated ---------------------. (b). Original copy of receipt Treasury Challan Number-------------- dated --------------amounting Rs.----------------deposited under Head of Account "0210 Medical & Public Health." ( c ).Attested copy of the construction of the Firms, if it is not a sole propristorship. (d).Attested copy of document of lawful owership, of occupation of the premises(i.e.purchase document,rental document etc)not required for renewal, if the document submitted earlier is still valid. (e).Attested copy of Tripura Sale Tax Clearence Certificate. (f).A sketch showing location and total floor area of the premises. (g).The certificate of experience(not less than 03(three) years in dealing with Homoeopathic Medicine to be obtained from Gazetted Officer /M.L.A /M.P./ in respect of the competent person). (h).A declearation of the competent person stating his willingness to work in the premises and that his name has not been included in any other licence and the name & address of places he worked during last 03(three) years. (i).Attested copy Trade Licence,if the premises is situated within Agartala Municipal Council/Nagar Panchayet. 2.I do hereby declare that the information furnished above are true to my knowledge and belief. I also state that I shall abide by the provisions of the Drugs & Cosmetics Act,1940 & Rules thereunder and instruction issued by the authority from time to time. I/We shall have no cause of action, if any action is taken by the licensing authority,in case of defection of incorrect/false information/documents produced as above by me/us. All documents submitted are countersigned by me on the reverse side. Nos. of enclosure :- Yours faithfully, Date : -------------------------. Full signature of the applicant. The Drugs & Cosmetics Rules,1945 FORM-19-B (See Rule 67-A). Application for licence to sell,stock of exhibit or offer for sale or distribute Homoeopathic Medicines. 1. I/We --------------------------------------------------------------------------------------------of -------------------------------------------------------------------------------------------------------are hereby apply for a licence to sell by retail/wholesale Homoeopathic medicines on the premises situated----------------------------------------------------------------------------------------------------------------- 2. The sale and dispensing of Homoeopathic medicines shall be made under the personal supervision of the following competent person in-charge. Name :------------------------------------------------------------------------------------------------- 3. A fee of Rs.----------------(Rupees-------------------------------------------------------------------------------only had been credited to Government under the Head of Account No."0210 Medical * Public Health)",vide challan No.------------- dated ---------------------------------------------------------------------- Dated---------------------- Signature of the applicant. Delate, which ever is not applicable. To be delate if Homoeopathic Medicines will be sold be Wholesale. &&&&&&&&&&&&& SPECIMEN DECLARATION OF COMPETENT PERSON. To, The Deputy Drugs Controller & Licensing Authority. Pandit Nehru Office Complex, Kunjaban. Government of Tripura, Agartala,799006. Subject :- Undertaking as competent person. I Shri/Smti -------------------------------------------------------------------------- is hereby declare that shall I work in the premises of Shri/Smti---------------------------------------------------------------------------------(Address)----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------and my name is not included in the licences of any other drugs shop. I have been working in the following places for last 03(three) years. Name and address of place. Period of work The above statement is true to my knowledgr and belief. Date : -------------------------------- Signature of the Competent Person In-Charge INSTRUCTION TO APPLICANT. 1. The application Form-B and 19B shall be carefully and properly filled in 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. 2. Strike out the word/words which is/are not applicable. 3. Every retail shop shall have at least one full time Competent Person. Qualification and Experience required for a qualified person/competent person 03(three) years experience in dealing with Homoeopathic medicine. 4. 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. 5. A separate sheets may be enclosed, if the space provided is found inadequate in any item. 6. 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. However no business shall be carried out by such person after the expiry of validity. If renewal application is not made within the validity or within 6(six)months of the expiry of vilidity licences shall be deemed to have expired under rule 63. 7. Licensee shall maintain an Inspection Book in the shop. 8. A sign. Board shall be displaced at the licensed premises. 9. This instruction should not be sent to the office alongwith application. 10. Fees deposited are not refundable even if the licence are not renewed. Application fees payable for retail/wholesale licence Rs. 250/-each. Additional fee @ Rs.50/- per month or part thereof 11.Any clarification, if required, may be had from the Inspecting Officer (Drugs) of the concerned area. (M.K.Pal). Deputy Drugs Controller Government of Tripur 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 )