SELF APPRAISALS FOR GRANT / RENEWAL OF LICENCES OF SALES CONCERNS. Sl.No. Details of Information Remarks 1. Name and Address of the Sales Concern 2. Constitution of the Firm, Proprietor / Partnership/ Firm 3. Name & Address of the Proprietor/ Partners/ Directors. 4. Whether partnership deed / MOA enclosed Yes No. N.A 5. Whether applied for Grant / Renewal of Licenses in Form 20, 21, 20B, 21B, 20F, 20G, 20BB, 21BB, 20A & 21A. Yes No. N.A 6. Whether applied in Statutory applications Forms in required copies, Form-19, 19A, 19AA, 19C. Yes No. N.A 7. Whether requisite fee is paid and challan enclosed Challan No. dated. Rs. Yes No. N.A 8. Whether plan & Layout of the premises submitted Yes No. N.A 9. Whether the area of premises complied with statutory requirement areas ________________Sq.mts. Yes No. N.A 10. Whether Rental / Lease Agreement enclosed Yes No. N.A 11. Whether Tax Receipt / Relevant document to Show the ownership of owner enclosed. Yes No. N.A 12. Whether the premises is suitable for stocking the drugs Yes No. N.A 13. Whether refrigerator or cold storage facilities provided and they are adequate. Yes No. N.A 14. Whether proper refrigerator receipt/ the proof of possessing Refrigerator is enclosed Yes No. N.A 15. Whether Registered Pharmacist/ Qualified person is appointed Yes No. N.A Name: Registration No. Date: 16. Whether the original Registered Pharmacist / Qualified Person Certificate of Pharmacist enclosed. Yes No. N.A 17. Whether affidavit of Pharmacist with required details is enclosed Yes No. N.A 18. Whether the photograph and photo stat certificates of Registered Pharmacist is enclosed. Yes No. N.A 19. Whether Relieving letter of the Pharmacist from the previous employer / Proof of Tendering Resignation Letter to the Employer at least one month prior to this application [Enclosed] Yes No. N.A 20. Whether intimation of the relieving of the Pharmacist intimated to the concerned Drugs Inspector Yes No. N.A 21. Whether competent person for Whole Sale dealings was appointed Yes No. N.A 22. Whether photo on Photostat copy of qualification of competent person enclosed. Yes No. N.A 23 Whether experience Certificate with required period and Particulars enclosed. Yes No. N.A 24. Whether Motor vehicle use for distribution the drugs is on the firm's proprietors name Yes No. N.A 25. Copy of Registration of vehicle enclosed. Yes No. N.A 26. Whether Original Drug licences enclosed (in Case of Renewal) Yes No. N.A 27. Whether all the above them from 4 to 26 submitted in duplicate set. Yes No. N.A. Signature of the Proprietor / Partner of the firm / Director Specific Remarks of the Recommended / Not recommended Inspecting Authority. Reasons for Not recommended: Date : Signature of Inspecting Authority. Remarks of the Licensing Authority Accepted / Rejected. Signature of the Licensing Authority.
