Form No.

19
[See Rule 59(2)]

Application for grant or renewal of a license to sell, stock, exhibit or offer for sale or distribute
drugs other than those specified in Schedule ‘X’.

1. I S/o Sh. Prop./Partner M/s

……………………………………………………………….............hereby apply for license to sell by
Retail/wholesale drugs specified in schedule C & C (1), excluding those specified in
schedule X and/or drugs other than those specified in schedule C, C (1) and X to The
provisions of The Drugs and Cosmetics Rules 1945 and also to operate a pharmacy on the
premises situated at

2. The sale and dispensing of drugs will be made under personal supervision of the
qualified person(s) namely: -
Name: S/o Sh.
Qualification: D./ B. Pharmacy, Haryana Pharmacy council Regn. No.:-………
Matriculate / Graduate having adequate experience as prescribed under act.
3. Categories of drugs to be sold: Biological / Non- Biological
4. Particulars for special storage accommodation: working order refrigerator.
5. A fee of rupees three thousands only has been credited to the Government account under
the head of account “0210 Medical & Public health-fee for grant of licenses vide T.V. No.
dated

Date: Signature…………………

( Prop./ Partner/Director )
 Form No.19
[See Rule 59(2)]

Application for grant or renewal of a license to sell, stock, exhibit or offer for sale or distribute
drugs other than those specified in Schedule ‘X’.
1. I Sunil Kumar S/o Sh. Kalu Ram Proprietor of M/s Jay Cure Pharmaceuticals Mohindergarh
hereby apply for license to sell by Retail/wholesale drugs specified in schedule C & C (1),
excluding those specified in schedule X and/or drugs other than those specified in schedule
C, C (1) and X to The provisions of The Drugs and Cosmetics Rules 1945 and also to operate
a pharmacy on the premises situated at Shop No.1,Phase 1, Shopping Complex, Kila Road,
Mohindergarh (District Narnaul)

2. The sale and dispensing of drugs will be made under personal supervision of the
qualified person(s) namely: -
Name: Sunil Kumar S/o Sh. Kalu Ram
Qualification: Passed Matriculation examination from Board of school education Haryana
in March 1996 and having adequate experience as prescribed in dealing with sale of drugs as astt.
Salesman with M/s Jindal Medical Hall, Mohindergarh from 1/4/2003 to 31/3/2007.

3. Categories of drugs to be sold: Non Biological

4. Particulars for special storage accommodation: working order refrigerator.

5. A fee of rupees three thousands only has been credited to the Government account under
the head of account “0210 Medical & Public health-fee for grant of licenses vide T.V. No.
338 dated 15/1/2007.

Date:7/9/2007 Signature…………………
Sunil Kumar S/o Kalu Ram
Prop. M/s Jay Cure Pharmaceuticals, Mohindergarh