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 than those specified in Schedule-X

Format of Affidavits

Application Form

Applicant Details

Establishment/Shop Details

Full Name of the Applicant

Name of Shop

Mobile Number

Type of outlet/shop

Retail

Whole Sale

E-Mail

Address of the establishment

Address of the Applicant

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Address Line 2

Address Line 3

Country *

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Country *

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State *

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State *

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District

Postal / Zip Code *

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Postal / Zip Code *

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3. *Categories of drugs-

4. #Particulars for special storage accommodation:

Particulars

# Required only if products requiring special storage are to be sold

Supervisors

The sale dispensing of drugs will be made under the personal supervision of a qualified person(s), namely -

Sl. No.

Name

Qualification (Regd Phst/Experienced Holder)

Sl. No.

Name

Qualification (Regd Phst/Experienced Holder)

Section

DECLARATION FOR THE CONSTITUTION OF FIRM

Licensee Details

Name of the Licensee

Untitled

Age (Not below the 18 years)

Mobile Number

Name of the firm

E-Mail

License No. (M/S)

Shop/Outlet Type

Retail

Whole Sale

Address

Village/Town *

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Post Office

Police Station

Country

State

District

Postal / Zip Code

Pharmacist/Competent Person Details

Name of the Pharmacist/Competent person

Untitled

Address

Registration No.

Village/Town *

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Name of Pharmacy Council

Post Office

ILP No (if Non-APST)

Police Station

Mobile Number

Country

E-Mail

State

District

Postal / Zip Code

Fees to be paid

Section

Person Authorized to Conduct Business

(i) If the Shop is run by Licensee him/her self

(ii) If the shop is run on rental/power of attorney basis (Enclosed copy of power of Attorney or Deed of Agreement and ILP of Attorney holder in case of non APST

Details of Power of Attorney/Rental Holder

Name of the Power of Attorney/Rental Holder

Age (Not below the 18 years)

Address

Village/Town *

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Post Office

Police Station

Country

State

District

Postal / Zip Code

ILP No. (if Non-APST)

Mobile Number

E-Mail

Declaration of Employee(s)

Full Name

Age (Not below 18 years)

Address of the employee

Village/Town

Post Office

Police Station

Country

State

District

Postal / Zip Code

ILP No. (if Non-APST)

Mobile Number

Image

Declaration

Certified that information furnished above are true to the best of my knowledge and belief. If any information given above is found misleading or false, the authority may initiate legal action as may deem fit and proper.

Section

CRITERIA/GUIDELINES TO BE FULL FILLED BY THE APPLICANT FOR GRANT/RENEWAL OF DRUGS LICENCE FOR RETAIL SALE/WHOLESALE (DRUGS THAN THOSE INCLUDED IN SCHEDULE X) IN THE STATE OF ARUNACHAL PRADESH

Affidavit by the Registered Pharmacist (As per specimen prescribed for Retail sale) and attested copy of Registration Certificate (up to date). For obtaining Wholesale DL only Matriculate (Class-X passed) or its equivalent with four years’ experience in dealing with drugs.
An Affidavit in by the PROPRIETOR/Licensee for compliance of the provision of D&C Rules 1945 (As per Specimen preserved).
An Affidavit declaring not to made doctor’s chamber inside the specified area of the retail shop (As per specimen prescribed)
Appointment Order of Pharmacist
Appointment order of Employee(s) (NB: Such appointment may be done by proprietor or Power of Attorney holder)
Consent letter to Licensee by the pharmacist
Constitution of firm: Declaration in Prescribed format (Enclose Power of Attorney/ Deed Agreement and other documentary evidence/ILP of the employees) other than owner/Attorney holder)
Documentary evidence of ownership or rental or other basis of the premise
Authenticated sketch map/ blueprint of the site of the proposed premises: An area not less than ten square meters. (to be submitted during obtaining Grant of New DL)
Inner line permit of the Pharmacist or in-charge of the qualified person and other employee(s) (in case of non Arunachalee)
ST Certificate of the applicant (To be submitted during obtaining Grant of New DL)
Inspection Report (To be obtained from concern area Drugs Inspector)

NB - All affidavit should be in Rs 50/- Non-Judicial Stamp Paper

I Agree *