Tot shefer ad Department of Pharmaceuticals Ufeasen Ministryof Cheriealstel certs Government of India PRADHAN MANTRI BHARTIYA JAN AUSHADHI PARI JANA Application for opening "Pradhan Mantri Bhartiya Jan Aushadhi Kendra” at S.No|| Particulars Details 1 | Name & Address of Applicant Status of Applicant Individual Entrepreneur [] Charitable Institute/Hospital ] NGO /Trust C} (Tick Appropriate Box) Government/ Government Nominated Agency [] Any Other [1] (Please specify) Registration Number of Organization, Date of Incorporation (if Applicable) Name of Contact Person Mobile No. / Landline No. / Email id Aadhaar Card Number PAN Number Location of the Proposed Store with Complete Address Name & registration no. of the pharmacist Declaratior 1. IMe have gone through the terms and conditions as mentioned in the guidelines for opening of Pradhan Mantri Bhartiya Jan Aushadhi Kendra and agree to abide by the same and appoint pharmacist for obtaining drug licence (in case applicant isnon-pharmacist). 2. IWehereby declare thatall the information as mentioned above is true to best of my knowledge. Ifany information is found tobe incorrect, my/our candidature is liable to be cancelled and may be subjectto legal/disciplinary proceedings. 3. Supporting documents are attached wherever required forinformation as provided above Date Signature Plac Name and Designation Note: Applications without Aadhaar Card shall be summarily rejected List of documents required for opening of Jan Aushadhi Kendra to be attached with Application Individual Institutions/NGO/ Charitable Government/ Govt Nominated Agency 1. Aadhaar Card Institute/Hospital etc. 1. Details of Department who has 2. Pan Card 1. Aadhaar Card allocated the space, along with 3. Certificate for disability | 2. Pan Card supporting documents/sanction order (only for disable applicants) | 3. Certificate for Incorporation 2. Pan Card 4, Pharmacist Registration | 4. Registration Certificate 3. Aadhaar Card Certificate 5. Pharmacist Registration Certificate | 4. Pharmacist Registration Certificate Ploase send application form to BUREAU OF PHARMA PSUs OF INDIA, IDPL Corporate Office Complex, Old Delhi - Gurgaon Road, Dundehera. Gurgaon-122016 (HR)werotaiat atte oT shafts sweat a Ufeatston wee BASU USS RR R “seria ard or site oe" ale & fore ater air frat siege ar ae sie Gar miaa at Refer anfacrra exeeret [] (agen ats et a) AReaw wer/eer OO enist/ pe O WROR/ SRO ETT ATT Cat] feat say ep ar Oo Wrest Ot daha wen, afm ert at fA (ae a) aaa fry ore are after ot aH aaa /ascgs Wet SHR ars eM tn ad Wen mend de Whe GM wT eer faega oa & eer wemiftee er al afk deter de aber 1 2 Beh ee rea coy st om eh Fee itr wee te Pr a te one A were /é 2 SQ eee weer &/ axe 8 Pe Story wet eT AR ree Fee Bore ea TS A Te ET TT Tg TT BR / wa Seca eq A AT Tor ate AR Re UE A ore oars a iT Tae | 3. oeRtas yarrisit a wearer wet a fry arraeaey Tear Hert Py OTE EL fete = eee wan: am ie ae Skee Uc kK OM UE WR RCRA oe & we vars fey aM ae sare seat wear / Taha / WER / RR Et Ta YAM aRega wen/eiftucs | 1, fart a Ran, RRA ear srafea wera & ‘re H gear wears /arga 4 Ser 2. SER wars 3 tos 4. orifice Soler wareraat ‘pen ae ater apt rat ease sf (Anas), atte taht rater afte, goer Reopens ts, Garber, Twa szz0re(eheae) we A |Address for Submi Application should be send in the prescribed format along with the required documents to below mentioned address in a closed envelope/cover clearly super scribed as “Application For The New PMBJK”. Please mention your email-ID in the application Form. To, Bureau of Pharma Public Sector Undertakings of India (BPPI), IDPL Corporate Office, IDPL Complex, Old Delhi Gurgaon Road, Dundahera, Gurgaon—122016 (Haryana)