Fill in Chemist Shop (Drug Licence) Affidavit

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Chemist Shop (Drug Licence) Affidavit

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The applicant and the shop
The pharmacist and the premises
Swearing

Step 1 of 3

The applicant and the shop

What is the applicant's full name (the person swearing)?Needed

For example: Ramesh Chander Verma

What is the applicant's father's or husband's name?Needed

For example: Late Sh. Om Prakash Verma

What is the applicant's age?Needed

A plain number. Digits only — no words and no units beside them.

For example: 47

What is the applicant's residential address?Needed

House / flat / plot no.

Street, sector or locality

City area and PIN code

Who is the licence applicant?Needed

the deponent, as sole proprietora partnership firm, through the deponent as an authorised partnera company, through the deponent as an authorised director

What is the name of the shop or firm?Needed

For example: Verma Medical and General Store

What is the address of the shop?Needed

House / flat / plot no.

Street, sector or locality

City area and PIN code

What licence is applied for?Needed

retail sale of drugs other than those in the schedules that need special conditionsretail sale of all drugs for which a retail licence is available, including prescription drugs

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AFFIDAVIT IN SUPPORT OF AN APPLICATION FOR A RETAIL DRUG LICENCE (CHEMIST SHOP)

I, __________, son, daughter or wife of __________, aged __________ years, residing at __________, do solemnly affirm and state on oath as follows.

1. That I am applying for a licence for __________ at the shop called __________, situated at __________, and the applicant for the licence is __________.

4. That I shall buy drugs only from licensed dealers against proper bills, keep the records of purchase and sale, the prescription register and the stock the law requires, sell prescription drugs only on a valid prescription of a registered medical practitioner, store drugs as their labels require, not sell expired, spurious or banned drugs, and allow the Drugs Inspector to inspect the shop and its records at any time.

5. That neither I nor, to my knowledge, any partner or director of the applicant has been convicted of an offence under the drug laws, or has had a drug licence cancelled or refused, or is otherwise disqualified from holding a licence, and that no other licence of this kind is held in the shop.

6. That I shall follow the Drugs and Cosmetics Act and Rules and the conditions of the licence, shall tell the licensing authority of any change in the premises, the pharmacist or the persons who run the business, and shall renew the licence before it ends.

DEPONENT: __________
Signature: ______________________________

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