Wholesale Drug Licence Application 62355a

GOVERNMENT OF WEST BENGAL Directorate of Drugs Control JALPAIGURI DISTRICT DRUGS CONTROL OFFICE Jalpaiguri District Additional Information Form for Grant of Licences to Sell Drugs (See Rule 64A of the Drugs and Cosmetics Rules)

To be enclosed with application in Form 19, 19A, 19B and/or to be furnished for Licence in Form No. 20, 21, 21A 20B, 20C, 20F, 20G 1.

2. 3. 4. 5.

6.

7. 8.

9. 10 .

Name & Address of the firm (with Telephone No., Room No., Floor, if any)

P.S. (for areas other than Kolkata) and Subdivision Location and Director (Rly Station, Bus Route and the Stoppage nearest and brief directory Actual floor space area of the proposed premises and height from floor to ceiling : A brief statement on construction of the premises (whether brick built, plastered and floor cemented roofing and ceiling) A sketch map showing situation is to be enclosed : How the premises is legally possessed and to be used for the licences? What are the copies of documents furnished? (Rent Receipt of owned tax receipt etc., copies to be enclosed) mention roofing and ceiling) A sketch map showing situation is to be enclosed : If Trade Licences / Tax Receipt from Local Govt./Panchayat has been enclosed Constitution of the firm and attested/Xerox copy of document produced in thereof (Name, Qualification, Age and Residential Address of the Proprietor/Partners/Directors) If power of attorney has been exercised Name, age, qualification and experience of the Qualified Person / Competent Person in charge.

M/S RELIEF DRUG HOUSE :

Ghogomali Fall Bazar Road Chayan Para,(Word No. 37, Holding No. 12/ P.O - Ghogomali, Siliguri - 734006 Dist - Jalpaiguri, West Bengal

:

BHAKTINAGAR, SILIGURI

:

Drug Control office to Champasari.

:

12.5 sqr. Ft. X 11 sqr. ft. = 137.5 Sqr. Ft.

:

The Room has completely made by bricks wall plastered and floor and ceiling cemented roofing and a Sketch Map submitted.

:

Rented and rent receipt submitted

:

Copy of Trade Licence submitted.

:

1. CHANDI DAS MANDAL ,H.S. ed, 40Yrs, Sukanta Nagar, Siliguri 2. NISHA BARMAN, HS ed, 30Yrs, Kharibari, Darjeeling 3. RANJIT BARMAN, HS ed, 38Yrs, Majhabari, Ghogomali, Siliguri 4. SASHI DEBSARMA, BA ed, 33Yrs, Rabindranagar, Siliguri

:

No.

:

RANJIT BARMAN, Age- 38Yrs, H.S. ed

11.

12 . 13 . 14 . 15 .

16 . 17 .

18 .

19 .

20 .

21 .

22 .

If letter of appointment indicating salary and acceptance of Qualified Person / Competent Person-incharge, along with copies of his Registration and Renewal Certificates/Educational Certificates and Certificate of Experience has been furnished? Name, address, age and qualification of the person responsible for operation of the Licence(s), if granted What other business including that in drugs is being carried out by the present/applicant(s) Is the application for grant or renewal in case of renewal, please note the DL No.(s) Was any application of the present applicant(s) for grant / renewal of Drug Licence(s) was rejected or was any licensed firm under Proprietorship / Partnership of the present applicant(s) was warned for violation of Rule or Licence(s) held by such firm was suspended / cancelled? Was the applicant ever warned prosecuted for selling drugs not of standard quality and/or spurious / adulterer drugs? Is it for an application due to change in constitution of a Licence Firm? If so, please note the date of such change and manner thereof, was documents has been furnished in copy? Was the Qualified Person/Competent Person-in-charge as mentioned against 10 ante ever convicted under the mentioned Drugs and Cosmetics Act, 1940 and 1982 of Dangerous Drugs Act, 1930, Poisons Act, 1919, Pharmacy Act, 1948 ? Has any Licence under Poisons Rules/Dangerous Drugs Rules been obtained in favour of the applicant Firm? Please confirm. In case of any intending Whole seller for Distribution / Stockiest ship, the name of the manufacturing Co and the proposed area may please be noted. Is the applicant Firm proposed to be a Grocery / Stationary / Dispensing Chemist / Medical Stores / Distributing Agency / Commission Agency / Importers / Exporters or any other besides this? Is there any other tenant / under the same Roof or covering? If so, whether the proposed premise are completely separated and has an identical entrance, without any connection with other possessors and/or residential portions?

:

Appointment letter and engagement letter submitted.

:

RANJIT BARMAN, HS ed, 38Yrs, Majhabari, Ghogomali, Siliguri

:

Only Drugs

:

For Grant

:

Present application for grant of Licence.

:

No.

:

No.

:

No.

:

No.

:

Whole Sale

:

Whole Sale

:

No.

23 . 24 . 25 .

26 . 27 .

Does the present applicant(s) carry on business in drugs elsewhere? If so, mention Name, Address and DL No. (s) What class or classes of Drug is/are proposed to be sold? Whether Refrigerator has been installed to stock for sale Drugs requiring cold storage, if so, make, machine No. and capacity are to be mentioned. If so, Refrigerator is provided has a declaration excluding such Drugs been furnished? Proposed working hours and days AM and/or PM to be noted (Also mention the weekly closing days, if any) Total No. of workers to be engaged :

:

No.

:

Biological and Non Biological Drugs

:

Samsung Refrigerator and 190 Ltr. Capacity

:

8 AM. to 6 PM. (Sunday Closed)

:

4 No’s Workers engaged.

I/We certify that all the above information are true to the best of my/our knowledge and belief and I/We understand that the applicatio with which such information as aforesaid have been furnished will be summarily rejected if any or mare of the information are found be false or misleading.

1 2 3 4 Signature of applicant (s)

Address: Ghogomali Fall Bazar Road, Chayan Para, P.O. Ghogomali, Siligur 734006 Dist - Jalpaiguri, West Beng Date ……………………………………………