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Application Form No: 19.
Additional Information Form (With 2 Copies of recent photograph of Pharmacist)
T.R. Challan No: 7 (Showing fees of Rs. 3000/- for Biological & Non Biological Licences
are deposited at R.B.I. / SB.I. Main branch.)
Xerox Copy of Trade Licence (Mentioning type of trade, name & address of the firm,
Proprietor / Partner / Directors name.
Xerox Copy of House rent bill (In case of rented shop premises)
Xerox copy of House Tax Receipt (Issued by Local Municipality / Government Tax receipt
issued by BLRO in case of Panchayat area)
Xerox copy of purchase records of Refrigerator (Issued in favour of the proposed firm)
Appointment letter of pharmacist (as per format affixed on Notice Board)
Xerox Copy of Registration Certificate of Pharmacist
Xerox copy of up do date renewal certificate of pharmacist.
Xerox copy of date of birth certificate of pharmacist.
Release letter of pharmacist from previous employer.
Affidavit of pharmacist (as per format affixed on Notice Board)
Affidavit of Proprietor / Partner (S) / Director (S) (As per format affixed on notice board)
Xerox copy of receipt of registration of firm ( In case of Partnership firm)
Memorandum of Article of Association (In case of Limited or Private Limited firm)
Copy of extract of resolution taken in the meeting of Board of Directors of Limited or
Private Limited firm regarding business in drugs & appointment of authorized signatory.
List of directors (in case of Limited & private limited firm.)
Sketch plan with actual dimensions, surrounding and signature of proprietor / partner /
Director of the proposed firm.
Required area of the proposed business premises 108 Sq. Ft (Floor area)
Required ceiling height 8`2 minimum.
The premises should be brick built, plastered and floor cemented with R.C.C. roofing
completely separated with identical and separate entrance.
Address of the firm in all related papers must be the same as noted in House Tax receipt.
House rent bill should be signed by the owner of the premises in full.
Documents as required in item nos: 9,10,11 & 12 above are to be verified by the P.R.O./
head Assistants of this office, prior to submission of application to this office.
Any other relevant papers which will be required during inspection / An affidavit by the
applicant stating that he will be liable for any false misleading or counterfeit paper if
detected during processing or after granting licence.