FORM 19 [See Rule 59(2)] Application for grant or renewal of licence (to sell, stock, exhibit or offer for sale or distribu tion) drugs other than those specified in Schedule X 1. I/We ....................................................................................................................................... ............................................................................................................................................... hereby apply for licence to sell by *wholesale/retail drugs specified in Schedules C and C(1) excluding those specified in Schedule X and / or drugs other than those specified in Schedule C, C (1) and X to the Drugs and Cosmetics Rules, 1945 and also to operate a pharmacy on the premises situated at ............................................................................................................... ............................................................................................................................................... ............................................................................................................................................... 2. ** The sale and dispensing of drugs will be made under the personal supervision of a qualified person, namely:(Name)........................................................................................................... (Qualification) (Name)........................................................................................................... (Qualification) 3. Categories to be sold 4. #Particulars for special storage accommodation 5. A fee of rupees ............................................................has been credited to the Government amount under the head of account ........................................................................................ Date:.................................... Signature * Delete whichever is not application ** To be deleted if drug will be sold only by wholesale # Required only if products requiring special storage are to be sold. QUESTIONNAIRE (To accompany application in Form 19) 1. Applicant's full name & age : 2. His/Her residential address : 3. Full Postal address of the premises (drug store) : 4. Exact Location of the premises : i. Municipal No. Survey No. : ii. Ward/Pakuty : iii. Town : iv. Taluk : District: 5. Applicants experience in drugs trade in number of years : 6. a. Whether the applicants wish to conduct Retail and/or wholesale dealings in drugs : b. If already Retails or Wholesale licence state licence no. and date : 7. What commodities other than drugs are stocked or proposed to be stocked in the same premises : i. Toiletries ii. Ayurvedic medicine iii. Herbo mineral medicines iv. Stationeries v. Provision goods vi. Homoeo medicines 8. Whether drugs are stocked at other premises owned by the applicant. If so quote number and date of licence : 9. Approximate value of drugs you intend to stock or passes already : 10. Average sale of drugs per day : 11. a. How many rooms are in the premises : b. Dimensions of the rooms : Length : Breath : Height : c. Is the premises provided with ceiling : d. Is it electrified : e. Type of flooring : 12. Has the premises been inspected by Drugs Inspector : 13. Name of the qualified person under Rule 65((IA) of Drugs Rules 1945 to be in charge of the Drugs Store : 14. Qualification and experience of the qualified person : 15. a. Are you stocking or intended to store and sell drugs requiring cold storage : b. Have you provided refrigerator if so mention made, type and whether run by electricity or kerosene : 16. a. Do you intended to conduct dispensing in same premises : b. Have you provided and equipped a separate dispensing room? If so mention dimensions (Refer Schedule N vide Rule 64(1) of Drugs Rules, 1945) : 17. Is any licence under the Dangerous Drugs Act or Prohibition Act held by you? If so mention number and date of such licence : 18. Have you been convicted at any time under Drugs Act 1940 : 19. Are you the owner or legal tenant of the premises : 20. House of business and working days : DECLARATION I state that the above information is true and agree to abide by the provisions of the Drugs Act 1940 and Drugs Rules, 1945 frame thereunder. Place: Date : Signature
