BIO-DATA AFFIX THE

PASSPORT SIZE
PHOTO

1. Name of the applicant :

2. Date of Birth :
3. Son of /Wife of :
4. Residential Address :

5. Permanent Address with Mobile No : As above

6. School at which studied :

Name & Address of the school Class studied Period studied

7. College at which studied:

Name & Address of the college Course studied Period studied
 8. Professional Experience:
Name & Address of the institution Period Post held Reasons for Leaving
where served

9. Whether the applicant ever holding the drug license? If so details

10.Whether the applicant family members ever holding the drugs licenses? If so details

11.Specimen Signature

1.

2.

3.

The details above furnished are true to the best of my knowledge

Place:
Date: Signature of applicant