APPLICATION FORM FOR IMPORT OF LIFE SAVING DRUGS, MEDICINES,

EQUIPMENTS UNDER NOTIFICATION NO. 50/2017-CUSTOMS, DATED 30.06.2017

1. Name of the Patient:-

2. Age:-
3. Address:-
4. Name of Disease:-
5. Name of the hospital where treatment is being received:-
6. List of Life Saving drugs/equipments under notification No. 50/2017-Customs(Deptt. of
Revenue):

S. Name of Drug Strength Quantity which may Period upto which

N. be imported the quantity
mentioned

7. Whether prescription and certificate from authorized

Treating specialist attached or not? Yes/No
8. Certificate from the treating Physician that drug is
a) Life saving for the patient (attached). Yes/No
b) Not manufactured and not marketed in India. Yes/No
9. Utilization certificate stating inter-alia that the
Medicine/Drug for which letter was issued earlier,
was utilized by the patient concerned. (This certificate
may be given by the treating physician) Yes/No
10. Certificate –Form 12B attached or not? Yes/No
11. Copy of record of treatment taken for the last 3 months. Yes/No
12. Copy of patient Aadhar Card attached or not? Yes/No
13. Copy of Applicant Aadhar Card attached or not? Yes/No
(Note: All the documents are mandatory. Please do not leave any column blank/Unanswered)

Place- Applicant Name-

Date- Signature -
 CERTIFICATE FROM THE TREATING SPECIALIST
(In reference to the Notification No. 50/2017-Customs, Dated 30.06.2017)

I, Dr. working as in

the Hospital hereby certified that

Shri./Smt./Mis./Master , Age
S/O,W/O, D/O,H/O is suffering from
(Diagnosis of Diseases) For the

last Days Months Years.

This is a life threatening disease. For his/her treatment, the following

Medicine/drugs/equipments are required in the quantity and strength (in the case of
drugs) given below:

S. Name of Drug Strength Quantity which may Period upto

N. be imported which the
quantity
mentioned

I hereby certify that above mentioned drugs/medicines/equipments are life-

saving to the patients and are not manufactured and marked in India. I recommend that
the above drugs/medicines/equipments should be imported for saving the life of the part.

Name of the Doctor-

Designation-

Name of the Hospital-

Delhi Medical Council Registration No.-

Signature of the Doctor with Date-

 UTILISATION CERTIFICATE

It is certified that Shri./Smt./Kum………………………………………………… is

suffering from………..………………………………………..(Name of Disease) has
been prescribed the following costly medicines for the recovery of
his/her Disease.

Name of the Medicine/Drug………………………………………………….. was

prescribed by me on………………………….for the period from
……………..……..to ………………………….. and the quantity supplied for the
period has been completely utilized.

Signature, Seal & Name

of the Treating Specialist.