Health Department FORM 19-A [See Rule 59(2)] Application for the grant or renewal of a restricted licence to sell, stock or exhibit 40b[or offer] for sale, or distribute drugs by retail by [* * *]40c dealers who do not engage the service of a qualified person 1. I/We............of..........hereby ..........41[Drugs other than those specified apply for a licence to sell by retail (i) ------------------------------------------------ 40d[* * *] in Schedules C, C(1) and X on the premises situated at...... ........ Drugs specified in [Schedule C(1)]41a, on the premises situated at..... or (ii) ---------------------------------------------------------------------------------- Drugs specified in [Schedule C(1)]41a, as vendor in the are ..... 2. Sales shall be restricted to such drugs as can be sold without the supervision of a qualified person under the Drugs and Cosmetics Rules. 3. Names or classes of drugs proposed to be sold ......... *4. Particulars of the storage accommodation for the storage of 41a[Schedule C(1) drugs on the premises referred to above. +5. The drugs for sale will be purchased from the following dealers and such other dealers as may be endorsed on the licence by the licensing authority from time to time. Name of the dealers.........Licence No........ 40e[* * *] 6. A fee of rupees ----------------- has been credited to Government under the head of account................ Date......... Signature......... * Delete if not required.
