KSPC - G

KARNATAKA STATE PHARMACY COUNCIL

514/E, I Main, II Stage, Vijayanagar, Bangalore – 560 104
Ph: 080-23404000, 23383142
E-mail: kspcreg@gmail.com, Web: www.kspcdic.com

Application for “Good Standing Certificate (GSC)”

To,

The Registrar
Karnataka State Pharmacy Council
Bangalore - 560 104

Dear Sir,

I, …………………………………………………………………… a registered pharmacist, bearing KSPC Registration No……………. dated

……….………… would request you to issue a “GOOD STANDING CERTIFICATE” and send the same to the Board
mentioned below:

NAME OF THE BOARD: …………………………………………………………………………………………………..………………………………….

ADDRESS: …………………………………………………………………………..….………………………………………………………
…………………………………………………………………..…………………………………………………………………
I furnish the following additional details for your Office records

1. Date of last renewal

(Renewal is mandatory to
obtain GSC)
2. Email ID

3. Mothers name

4. Name of husband/wife

5. Present Residential Address with

contact no & E-mail:

6. Permanent Address in Karnataka

with contact no & E-mail:

7. Office Address :

8. Alternate Contact person:

9. His contact No:

The following documents are enclosed herewith:

1. A demand draft for Rs.5,990/- in favour of “KSPC, Bangalore” bearing No. …………… dated
........................drawn on ................................…………………..… Bank.
or
An amount of INR 5,990.00 is transferred to KSPC Account No. : 52117060304;
Account Name: “Karnataka State Pharmacy Council"; Account Type: Savings Bank;
Bank Name: State Bank of Hyderabad; Branch : Vijayanagar, Bangalore; IFSC Code : SBHY0020859
through online Net / Card transfer on………………….. transaction No:……………………..

2. Photocopy/scan copy of registration certificate issued by KSPC.

Thank you,

Yours Sincerely

Signature Date: ........................