Form - 19 ( See Rules 59 (2)) Application for grant or renewal of a License ( to sell, stock, exhibit or offer for sale or distribution) of drugs other than those specified o in Schedule - x. 1. I / we .................................................here by apply for license to sell by wholesale/ retail drugs specified in schedule C and C(1) excluding those specified in schedule X and / or drug other than those specified I Schedule C, C (1) and X to the Drug and Cosmetics rules , 1945 and also to operate a pharmacy on the premises situated at ........................................................ ............................. 2. The sale and dispensing of drug will be made under the personal supervision of a qualified person,, namely:- (Name)...................................(Qualification) (Name)....................................(Qualification) 3. Category of drugs to be sold. 4. Particulars for special storage accommodation. 5. A fee of rupees ............................................... Has been credited to the Government account under the head of account.................................................... . Date: Signature:
