BEFORE THE NOTARY PUBLIC: CUTTACK

AFFIDAVIT
I, Shri Sanjay Kumar Samantaray, aged about 36 years, S/o- Biswanath Samantaray,
resident of, Longhar, Srikrushnasaranpur, Panditgaon, Khallikote, Ganjam, Odisha 761029
do hereby solemnly affirm and state as follows:
1. That, I am the deponent of this affidavit.
2. That, I am the Proprietor of the proposed firm M/s NARAYAN DEVICES PVT LTD at Plot
No 778, At- Panchasakhanagar, Dumduma, Near ITER Engineering College, Po/Ps-
Khandagiri, Bhubaneswar, Odisha 751030 applying for the grant of Drug license.
3. That, all the documents related to the premises and all other documents are either in
original or in Xerox are genuine, true and proper. None of the document is either fake
or duplicate.
4. That, further I declare that I will not use the premises for any other purposes other
than medicine business.
5. That, I hereby further undertake and declare that any change of the licensed premises,
constitution of the firm will be intimated to the office of the Drugs Inspector,
Bhubaneswar-II range immediately.
6. That, I will be responsible for any type of litigation arising related to
land/property/premises.
7. That, I further undertake and declare that in the event of any statement above is found
to be wrong and improper, I will be held liable and responsible for cancellation and also
punishable under the court of law.
8. That, the facts stated above are true and correct to the best of my knowledge and belief.
Identified by

Advocate Deponent
Certificate
The above named deponent being identified by ______________________, Advocate
solemnly states and affirms before me that the facts stated above are true to the best of
his knowledge and belief.
Place: Cuttack Notary Public, Cuttack
Date: