08/03/2023, 00:19 https://onlineapp.pmbi.co.in/print_reg_frm.aspx?

regno=unclNlmsisVD74XGVu0lBqcYkUnrFUeSVzwncl0onUy2qIwwclld

Pradhan Mantri Bhartiya Jan Aushdhi Pariyojna

Payment info with application detail

Request No. : Reference No. : Application No. :

REQ/000125745 AF/00093517 BPPI/06/WB/CAT1/00003255

Applicant Category Type : *

Women Entrepreneurs

Application Detail

Name of Applicant : Permanent Address : State : District :

nivedita pal datta c-57, himanchal vihar, matigara, West Bengal darjeeling
siliguri, darjeeling, west bengal

Mobile No. : Alternate Phone/Mobile No. : Email-ID :

8250637740 918250661108 slgnivedita@gmail.com

Aadhar No : 731939469925 PAN No. : AKFPP4934L

Store Opening Details

Proposed Store Complete Address : Proposed Store State : Proposed Location :

mahika, new kawakhali township, opposite to North West Bengal District
Bengal Medical College,

Proposed Store District : Block (Optional) : Proposed Store PIN Code

DARJEELING MATIGARA :
734012

Proposed Store Mobile No : Proposed Store Phone No. : Proposed Store Email-ID Are you
9382304425 918250661108 : Pharmacist * :
slgnivedita@gmail.com
Yes No

Bank Statement of last 6 months :

Download File

      I Accept all Terms & Conditions

1. I have gone through the terms and conditions as mentioned in the guidelines for opening of Pradhan Mantri Bhartiya Jan Aushadhi Kendra
and agree to abide by the same.

2. I/We hereby declare that; all the information as mentioned above is true to best of my knowledge. If any information is found to be incorrect,
my/our candidature is liable to be cancelled and may be subject to legal/disciplinary proceedings.

3. I/We hereby declare that; I have gone through the terms and conditions as mentioned in distance policy and certify that there is no violation
of PMBJK distance policy at proposed location.

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