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    Applicant Declaration Form Pharmacist

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    fsdsgfsdfds ffsdfdsf
    pharmasist form

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Applicant Declaration Form Pharmacist

    Uploaded by

    fsdsgfsdfds ffsdfdsf
    19 views2 pages
    pharmasist form

    Original Title

    Applicant declaration form Pharmacist

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    pharmasist form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    19 views2 pages

    Applicant Declaration Form Pharmacist

    Uploaded by

    fsdsgfsdfds ffsdfdsf
    pharmasist form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Applicant/Authorized Person Affidavit Form

    Licence Nos: .................................................


    ..................................................
    ..................................................

    Name:-.....................................................................................................................................................................................
    Father’s/Husband’s Name:-.....................................................................................................................................................
    Address:-..................................................................................................................................................................................
    .................................................................................................................................................................................................

    I hereby declare that:

    1. I/Authorized person has been granted Retail/Wholesale Licence in Form No. 20/21, Form 20-B/21-B with the name
    ................................................................................................................ which is/are valid up to .......................................

    2*. I/We ..............................................................................., declare that earlier


    Mr./Miss./Mrs. ..................................................................................... B.Pharma/D.Pharma, Reg.no. ...............................,
    date of issue ............................, validity up to ...........................
    Mr./Miss./Mrs. ..................................................................................... B.Pharma/D.Pharma,Reg.no. ...............................,
    date of issue ............................, validity up to ...........................
    Mr./Miss./Mrs. ..................................................................................... B.Pharma/D.Pharma,Reg.no. ...............................,
    date of issue ............................, validity up to ...........................
    was/were working as the Registered Pharmacist/Competent person in my shop/firm. He/She will continue to work as
    Registered Pharmacist/Competent person in my shop/firm.

    3*. I/We ..............................................................................., declare that earlier


    Mr./Miss./Mrs. ..................................................................................... B.Pharma/D.Pharma,Reg.no. ...............................,
    date of issue ............................, validity up to ...........................
    Mr./Miss./Mrs. ..................................................................................... B.Pharma/D.Pharma,Reg.no. ...............................,
    date of issue ............................, validity up to ...........................
    Mr./Miss./Mrs. ..................................................................................... B.Pharma/D.Pharma,Reg.no. ...............................,
    date of issue ............................, validity up to ...........................
    will not work as Registered Pharmacist/Competent person in my shop/firm, and his/her name needs to be deleted.
    4*.I/Any Director/Partners/Society Members/Trusty, have now appointed
    Mr./Miss./Mrs. ..................................................................................... B.Pharma/D.Pharma, Reg.no. ...............................,
    date of issue ............................, validity up to ...........................
    Mr./Miss./Mrs. ..................................................................................... B.Pharma/D.Pharma, Reg.no. ...............................,
    date of issue ............................, validity up to ...........................
    Mr./Miss./Mrs. ..................................................................................... B.Pharma/D.Pharma, Reg.no. ...............................,
    date of issue ............................, validity up to ...........................
    to work as Registered Pharmacist(s). Medicines will be sold under personal supervision of Registered Pharmacist.
    purchase and sale record will be maintained by Registered pharmacist.

    5. I/Any Director/Partners/Society Members/Trusty, have now appointed


    Mr./Miss./Mrs. .......................................................................................................................................................................
    Mr./Miss./Mrs. .......................................................................................................................................................................
    Mr./Miss./Mrs. .......................................................................................................................................................................
    to work as Competent Person. Medicines will be sold under personal supervision of Competent Person. All purchase
    and sale record will be maintained by Competent Person.

    *. As applicable

    Place:-.................................. Name :-.................................................

    Date:-................................... Signature:-............................................

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