GOVERNMENT OF WEST BENGAL

Directorate of Drugs Control

JALPAIGURI DISTRICT DRUGS CONTROL OFFICE
Jalpaiguri District
Additional Information Form for Grant of Licences to Sell Drugs
(See Rule 64A of the Drugs and Cosmetics Rules)

To be enclosed with application in Form 19, 19A, 19B and/or to be furnished for Licence in Form No. 20, 21, 21A
20B, 20C, 20F, 20G
1.

2.
3.
4.
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6.

7.
8.

9.
10
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Name & Address of the firm (with

Telephone No., Room No., Floor, if
any)

P.S. (for areas other than Kolkata)

and Subdivision
Location and Director (Rly Station,
Bus Route and the Stoppage nearest
and brief directory
Actual floor space area of the
proposed premises and height from
floor to ceiling :
A brief statement on construction of
the premises (whether brick built,
plastered and floor cemented roofing
and ceiling) A sketch map showing
situation is to be enclosed :
How the premises is legally
possessed and to be used for the
licences? What are the copies of
documents furnished? (Rent Receipt
of owned tax receipt etc., copies to be
enclosed) mention roofing and ceiling)
A sketch map showing situation is to
be enclosed :
If Trade Licences / Tax Receipt from
Local Govt./Panchayat has been
enclosed
Constitution
of
the
firm
and
attested/Xerox copy of document
produced in support thereof (Name,
Qualification, Age and Residential
Address
of
the
Proprietor/Partners/Directors)
If power of attorney has been
exercised
Name,
age,
qualification
and
experience of the Qualified Person /
Competent Person in charge.

M/S RELIEF DRUG HOUSE

:

Ghogomali Fall Bazar Road Chayan Para,(Word No. 37, Holding No. 12/
P.O - Ghogomali, Siliguri - 734006 Dist - Jalpaiguri, West Bengal

BHAKTINAGAR, SILIGURI

Drug Control office to Champasari.

12.5 sqr. Ft. X 11 sqr. ft. = 137.5 Sqr. Ft.

The Room has completely made by bricks wall plastered and floor and
ceiling cemented roofing and a Sketch Map submitted.

Rented and rent receipt submitted

Copy of Trade Licence submitted.

1. CHANDI DAS MANDAL ,H.S. Passed, 40Yrs, Sukanta Nagar, Siliguri

2. NISHA BARMAN, HS Passed, 30Yrs, Kharibari, Darjeeling
3. RANJIT BARMAN, HS Passed, 38Yrs, Majhabari, Ghogomali, Siliguri
4. SASHI DEBSARMA, BA Passed, 33Yrs, Rabindranagar, Siliguri

No.

RANJIT BARMAN, Age- 38Yrs, H.S. Passed

11.

12
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13
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14
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15
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16
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17
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18
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19
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20
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21
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22
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If letter of appointment indicating

salary and acceptance of Qualified
Person / Competent Person-incharge, along with copies of his
Registration
and
Renewal
Certificates/Educational Certificates
and Certificate of Experience has
been furnished?
Name, address, age and qualification
of the person responsible for
operation of the Licence(s), if granted
What other business including that in
drugs is being carried out by the
present/applicant(s)
Is the application for grant or renewal
in case of renewal, please note the
DL No.(s)
Was any application of the present
applicant(s) for grant / renewal of
Drug Licence(s) was rejected or was
any licensed firm under Proprietorship
/
Partnership
of
the
present
applicant(s) was warned for violation
of Rule or Licence(s) held by such
firm was suspended / cancelled?
Was the applicant ever warned
prosecuted for selling drugs not of
standard quality and/or spurious /
adulterer drugs?
Is it for an application due to change
in constitution of a Licence Firm? If
so, please note the date of such
change and manner thereof, was
documents has been furnished in
copy?
Was the Qualified Person/Competent
Person-in-charge
as
mentioned
against 10 ante ever convicted under
the mentioned Drugs and Cosmetics
Act, 1940 and 1982 of Dangerous
Drugs Act, 1930, Poisons Act, 1919,
Pharmacy Act, 1948 ?
Has any Licence under Poisons
Rules/Dangerous Drugs Rules been
obtained in favour of the applicant
Firm? Please confirm.
In case of any intending Whole seller
for Distribution / Stockiest ship, the
name of the manufacturing Co and
the proposed area may please be
noted.
Is the applicant Firm proposed to be a
Grocery / Stationary / Dispensing
Chemist / Medical Stores / Distributing
Agency / Commission Agency /
Importers / Exporters or any other
besides this?
Is there any other tenant / user under
the same Roof or covering? If so,
whether the proposed premise are
completely separated and has an
identical entrance, without any
connection with other possessors
and/or residential portions?

Appointment letter and engagement letter submitted.

RANJIT BARMAN, HS Passed, 38Yrs, Majhabari, Ghogomali, Siliguri

Only Drugs

For Grant

Present application for grant of Licence.

No.

No.

No.

No.

Whole Sale

Whole Sale

No.

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25
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26
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27
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Does the present applicant(s) carry on

business in drugs elsewhere? If so,
mention Name, Address and DL No.
(s)
What class or classes of Drug is/are
proposed to be sold?
Whether Refrigerator has been
installed to stock for sale Drugs
requiring cold storage, if so, make,
machine No. and capacity are to be
mentioned. If so, Refrigerator is
provided has a declaration excluding
such Drugs been furnished?
Proposed working hours and days AM
and/or PM to be noted (Also mention
the weekly closing days, if any)
Total No. of workers to be engaged :

No.

Biological and Non Biological Drugs

Samsung Refrigerator and 190 Ltr. Capacity

8 AM. to 6 PM. (Sunday Closed)

4 Nos Workers engaged.

I/We certify that all the above information are true to the best of my/our knowledge and belief and I/We understand that the applicatio
with which such information as aforesaid have been furnished will be summarily rejected if any or mare of the information are found
be false or misleading.

1
2
3
4
Signature of applicant (s)

Address: Ghogomali Fall Bazar Road, Chayan Para, P.O. Ghogomali, Siligur
734006 Dist - Jalpaiguri, West Beng
Date