APPLICATION FOR CHANGE OF REGISTERED PHARMACIST £Piam Name From ig G. Amala Amala medicals az -qeles-l, OPP MPpO office mer Tipati Rood, punganur | Chittoor ' etl. 2¢ amralathes grail. om gy PANG $ 1616629597 Assistant Director ‘Sub: - Application for ‘change of Registered Pharmacist- Requesting - Regarding. UWe q. fimala - _ the Proprietor! Partners of Mis Amola meol?cale , are Holding Drug Licences in role - NUR Form 20/Aplio/ou/ame~ 14y334/21/aphobyl “our present’ Recisteed Phamacist. Sri K. Onna Mahtturoai RP.No._2 has resigned in our shop. Hence we have uppointed new Pharmacist Sri KR Madhurt —.RPNo. 153.082 JA with effect from 06 fou lsory Hence we are here with enclosing our original Drug Licence and required documents for your kind perusal and necessary actions AN change of fivm name forom = frmeda Maite ee meatdals w.e-P- 06 lot] 20m Yours Faithfully, G-Amalo Proprietor! Partuer/Direetor Date: Enel:GOVERNMENT OF ANDHRAPRADESH cs [DRUGS CONTROL ADMINISTRATION Recisored Pharmacist FORM 20 UMA MANESHART and REGNO=26525/82 (see nue 61 (37) LICENCE TO SELL.STOCK OR EXHIBIT [ OR OFFER ] FOR SALE OR DISTRIBUTE DRUGS BY RETAILOTHER THAN THOSE SPECIFIED IN [ SCHEDULES C,C{1) AND X| LG AMAA Proretcr of M/SAMALA MEDICALS Js here by Scene to sl.stock or exhib for offer} for sale or distribute by reall drugs other thanthose specie in Schedules (Cand Cit) and) of the Drugs anc Cosmetics Rules 1945,* and to operate # pharmacy on the premises stuated at (22-48 /45-4, OP MPOO OFFICE MBT ROAD , PUMGAMUR, Chittoor, (Dist) subject 1 the conditions specified (below and the provisions ofthe Drugs anc Cosmetics Act, 1940 and the rules thereunder. |2. The scence iniese sooner suspended or cancelled, shal romain valid perpatualy. However, the compliance with the conditions of eonce ond the rovaiors os Oruge and Coumeten Act, 1940 (23 of 1080) and the Drage and Cosmetics Rules, 1045 shale asrensed ‘at leas an once in ree yours 0” 88 needed Se porn based approach .Name{s) of qualified person(s) in charge KCUMA MAMESWARI , RegNo. 24535/42,, DT:15/02/1996(0.0.: 21/02/2018) 4.categories of drugs : Drugs Other than these specified in Schedules C, C{1) and x) cence No:AB/10/04/2018-144374 ‘This iso Digitally Signed Document BY ‘AMC AAROTA. g Date: 09/03/2018 teh, suas saaeeatsete * Delete if not apoticablePharmacist (See Rule 61 (23) REGNO=24535/07 LICENCE TO SELL,STOCK OR EXHIBITIOR OFFERJFOR SALEOR DISTRIBUTE DRUGS BY RETAIL DRUGS SPECIFIED IN ‘SCHEDULES C AND C(1)[EXOLUDING THOSE SPECIFIED IN SCH} LG AMALA Popietor OF M/S AMALA MEDICALS: Is here by licenced to sel, stock or exhinit [or offer] for sale or distribute by retail the folowing categones of Drugs specie’ in ‘Schedules Cand C(1){ Excluding those specified in sch.X] tothe Drugs and Cosmetics Rules 1945 and to operate a pharmacy ‘on the premises situated at 27-48/45-1,0PP MPDO OFFICE MBT ROAD, PUNGANUR, Chittoor (Dist) subject to the ‘condticns specified below and to the previsions of the Drugs and Cosmetics Act, 1940 and the rules thereunder. 22. The Roence uniess sooner suspended « carceled, shall remain vakd peypetual. However. fre compllance wit the conditions of toence ‘and tie provisions of he Drugs anc Cosmescs Aci, 1940 (23 f 1980) ana the Orugs anc Cosmatcs Rules, YO4S shall be assessee ‘ot ess ian once n Tver Years 0° 8s needed a er Nek based approach +3. amas) of qualified person(s) in charge: KUMA MAHESWARI , RegNo. 24535/A2 , DT:15/02/1996(0.0.3: 21/02/2018) 4. Categories of drugs : Drugs Specified In Schedules C And C1 ){Excluding Those Specified In Sch.X]. cence No:AP/10/04/2018-144375 This By ic» Digally Signed Document Uoensing Authority Conditions OF Licence {This icone sal be displayed in a prominent place ina par ef he premises open othe publi. 12 The cence shall report the licencing authority any change in the qualified staf iecharge within one month af such change. 3.[P] Omid by GSR IEA 7-1-1986 (w 0 7-1-1986), 4. Hts ences anus el stock or exsbit for sal o disriburc, during the cureacy of he cence. adit catagories of Drage ted in [Seeds C and C()(Exclaling those specified im Sch X)_ bat ot inched inthis cence. you should wpply othe Meeming abort for te secenary pemusion This lcexce will Be dcemed io eens 6 Me calegones of Grp in espe OF WHC suc peTMAC given This permscoe tal be ended onthe Licence the licensing authority ‘5 No drug stall be sold unesssoch drug is purchased under cash or Credit memo from x duly licensed dealer ora uly licensed) manufacturer. 4 The eemce tall inform the Licensing Authority in writing in the event af any change in the constittion ofthe Fin apeating under the licence: Where any change in the consitetioe of the frm akes place. the caren iceacs shall be deemed tebe Vall fr «sasimare pared (eft mechs fm dae on wich the change acs place unless the meant. afresh licence es been ken from te Lisesing Autrey the mame of thf wh the changed constero ESE) Government of India Bee ecard etek caliente ae eiior be eorS omy / Your Aednear No. : 9007 3552 0029 “Wi: Onb4 70M Ga ‘sonose / INFORMATION 1B eteiongm ann deoay Orage 36 fea apsds 0 oS ab pb tye Dace Bs ks 8S Sioa aroeosore at serseauoend ets 1 rsdn Ubal bands paren ong ‘Sioksen agp deer Jind meter cy ae Soest oh byanantd md oo etm ne See enhtate One tebe eines OFFS aatow ort opts tee pce 8 ciara meant ge ommpuerneon Scandawers maedeaged ooo . oe Saco Seeman ere 15 Dang sed etn ard wD ere aes a, 1 ef Sous Dadeca radian ents 86 at, etre oo Sires cotrecaraaeh; Saas echt age yr tg OA me ‘nr olden re tension 108} 008 ‘stand rom atopy OS est ee ‘see nenmmeysacn rarer Per (2 horus ene an oe tes rg ee eet ‘steer i UOAopand merece ogee oF OR me ‘Torney mln whois GR Some op mane | nanan er read mean eb pt G-AmoalaGranalcrpocunenisy URC URTAT ION OF THE Pi REGISTERED Pe 1p Rame 2 Full Name (Block Letters) 3. Father’s/Hestand's Name and his profession 4 Age 5. Permanent Address (Proof to be attached) Present Residential Address with Contact tel/cell number 7. Educational Qualification B. Details of Earlier Occupation For last five years Whether You / Your Spouse are in possession of any Ucences under Drugs and Cosmetics Rules Earller or Present 2 If yes, Details 10. Whether at any time Your / Your Spouses Drug Licences Cancelled? If yes, Detalls Whether You / Your Spouse st any time convicted under any Criminal tave ? if yes, . Either alone or with any body, You / Your spouse involved in any Drug Cases ? If yes, Datails 13. Are You /Your spouse convicted / Acquitted in any Cases Under Drugs and Cosmetic Act, 19402 Ives, Details 14, Are you studied the Rules and Reguiattons of Orugs and Cosmetics Act, 1940 and Rules 1945 and uisdér-Stand Responsbilities of a Licensed De Certified that the above inform; in ease if any above 723 Rithvile medicals | Ke R. Madlhurt) rss rorr et on L_| 4-36, Behtrad Ke&BV School, Natkabanda, Punganur chittnor DO B pharmacy pharmacist No No No No NO Ke R-MoclhuatSPECIAL DECLAR IN OF REGISTERED PHARMACIST LKR Moclhuxt—. S/e/dD/o_K-R Ramanatah agect ebout Q3_ years, residing ry D.No..9- 36, Bebtnd KGBY Cchool, Nala banda Punganur —Chittony (pt) __(Mandal), Chittoor District. and state“ 1 ‘oath as follows: 1 am @ Registered Pharmacist/Qualified Person with certificate bearing Now tS 3082 /AL dt: 25 -O8- 2022 Ihave been engaged = as-_—=Ss employee/Proprietor/Partner/ = by WSs and the constitution of the above shop _Q.Armala is the proprietor/Partners of the said shop I situated F at - i (Mandal), Chittoor District since beg asta time :d as full time Registered Pharmacist/Qualified Person. Twill not work in any other firm in any capacity as long as I continue as the Registered Pharmacist/Quelified Person of M/s, —_____—— panganux. “chittoan ‘Mandal, Chittoor District. Further, | declare that ] am not doing any further studies In any course in any University after completion of my BD. Pharmacy/ B. Pharmecy/ case of my leaving the above firm, 1 will give advence ‘notice of one month in writing to the license holder will mark @ copy of the same. to Gistrict licensing authority an¢ area Drugs Inspector. 1 also declare that the above matter herein is true end correct to the best of my. knowledge. If it is found incorrect, the authorities may take leaal action against me as per rules. will be held re onsible for anythi of drugs act and 1 9 happens during the sale of crus ed acts during my serv Ds ke R«Moolhert+ IN-ap77907390872900 2 of Aor2nas.onse PM | NEWAMPACG (SV)/ap18080408! AP-GTAY AP-CHT/aparwtates 111012308001 JT SRO CHITTOOR (FO) 1 SUBIN-APAPre0BoHos497Sz96561 40620" . 2K AMADHURY Desc Propet Deseo Consioration Price (Ps rst Pany Not Applicable KAMADHURI : 20 (Twenty ny) f 2024 to 2028 om | CHITTOOR 1: 9177744230 EE (Declaration of Registered pharmaci st/qualified person) + eee 1,KeR.MADHURT, aged about 24 years D/O E.R. ‘Ramanai ah, Hinau, residing at DNo.9-36 behind KGBY Schoo}, jakkebanda, anur Town, Punganur Post and Mandal,Chittoor Dist .AP- Pung (nadhaar Card No.7965 7268 7127 and Mobile No . 75695 78300) do hereby declare as follows: 1 am a Registered Pharmacist/quelified person with Loti ficate bearing No.153082/A1 dated 25-08-2022, engaged Se full time employee in B/S 7 RITHVIK MEDICALS, D.No.27-$0/45=1, opp.to MPDO's Office, MBT Roady anur Town, Punganur Post ng Mandal, Chittoor Dist~A.P-517: I will supervise the ang Mandthe Drugs in this Shop as required by Rules of Druge & Cosemetics Act and Rules thereunder. 2. I will not work in any other firm in any capacity as long as my services in the above shop, In case, I leave the above 98 RY seeTii give advance Rotice to the District Licensing w Ar R Moalhurt @he CNtd..Der2e0 "Y 0004233813 Authority and also to the Shop.a2- 36 previously I wotked inM/S = NIL and Teniered my resignation w.e.f, NIL 4, t also declare that the above matter herein is true ind correct to the best of my knowledge and belief. I will be held responsible for any contravention that happens during the sale of the Drug in this shop. My specimen Signatures are given below. L KeR+Modhust My specimen Signature! SIGNATURE CF PHARMACIST. 1. Ae R Madhuat » Ke Rs Madhurt 2K R Moolhut Witness by Proprietor, > &- Amal Signature. Travan anap iho ut AP Cal vatloor HO. AP. CellKeReMoclhuwtEe BR: MadhuatWW-AP77907 190866957 iesuod Date O4-Apr-2026 02:50 PM NEWIMPACG (SVV apt 8090404/ AP-CTRY AP-GHTiapanwkahu 11012900003 Jt SAO CHITTOOR (f.0) Retorance SUBIN-APAPrBoBoanada!9y7e00705470 Purchased GAMALA Cotsdraton Price (Rs Fret Party GAUAA Second Party Not Applicable Paid By (For wom) GAMALA 20 Stamp Dury Amounts.) emia Lie (Tworty ony) SELF DECLARATION, I,G.AMALA, aged about 36 years Wife of A.Prakash,Hindu, Business, residing at D.No.28-136 Kothapeta, Punganur ‘own, Punganur Post and Mandal, Chittoor Dist.ar. do hereby declare as follows: 1. I am the Deponent herein, 2, I declare that I was running Medical@ Shop under the Name and Style of M/S AMALA MEDICALS at D.No.27-48/45-1, Opp. to MPDO Office, M.B.T.Road, Punganur Town, Chittoor Dist. 3. I submit that later on as per the advise of Astrologer Pandiths and our customs, I wave changed the said Shop as RITHVIK MEDICALS in the said Address. Since then, my shop name is RITHYIK MEDICALS. 4. This declaration is required to be produced before the concerned Authorities for the purpose of proving and establishing that I have changed my medical shop mm. = mame under the style of .° RITHVIK MEDICALS, and running the said shop ef the same address. Therefore, I am making his decla: Oe . Ss ov % G AMX DECLARANT. LAH6.15 ~ Rene? watts NRE TB oedaze 128.2012 0004233812 #2 54, ioevanopoll (Vi & f ‘Chisea UCR Cal ascot iEartificate No. #52282 19. Fagg of Reogistoation 25-08-2022 This ts lo Certify that. Within signed BR Madhurt Saat K_R MADHURI Hi / Daughton of. K R RAMANAIAH whose date of hiodh és 22-05-2000 tas been daly and ts entitled to all the privileges granted under the Pharmacy Act 1948 (8th of 1948) Tr witeoss eaters of are hereatth affived the seal ‘he Andhra Pradesh Pharmacy Councitand the jure of the Reegistrar of the said Phannacy Mu. (Note : Pass Book issued SLNo. ~~~ ~~~ ~~~ N Registration to be renewed for every five years Take this asmnotice U/s 242) r/w Rule 78 (1) This Certificate shall remain in force til G1st December, 28 days of geece upto 34st Merch macy Councl and is issued 20 thePharmacist Name: K R MADHURI Registration No 153082 /A1 SNo Place Of Work / Study Working As From To Remarksee ee ee ae a a a oe a ae SAASTRA COLLEGE OF PHARMACEUTICAL EDUCATION & RESEARCH Approved by AICTE & PCI, New Delhi, Affiliated to JNTUA, Anantapur Managed by Venkateswara Educational Society Varigonda Village, T.P. Gudur Mandal, Nellore Dist., A.P. Pin: 524 311. TRANSFER AND CONDUCT CERTIFICATE 018 AdmissionNo. [JJ] Roll No. | 2K R 2a Name of the Student in full: _K.R. MADHURI (in Block Letters) Name of the Father: [4.2 . RAMANAIAH Nationality INDIAN Religion : HINDU Community:___ SC (MALA) Sex: FEMALE Date of Birth as entered in the Admission Register _ 22 - 05 - 9000 (Both in figures and words) TWo Two - Zeko FIVE - TWO ZERO ZERO ZERO Admitted on _Q1- O7- imo 15. phazoaagy. course Date of leaving the College -12- | ‘The course from which he/she leaves B. Bozoaasy ‘Whether qualified for next higher course = hs is ‘Whether he/she paid as dues to the College ai Woh = Conduct and Character oe PRINCIPAL = Riel == Fuloralegsli&63Ogmell-com 96766 29 SFE FORM 19 [See Rule $9(2)] Application for grant or renewal of a licence to sell, stock, exhibit or offer for sale, or distribute drugs other than those specified in Schedule X RITAVUG.. MEDI CALL. hereby apply for licence to sale by wholesale/retail drugs pecteinilin Schedule C and C{1) andexeluding those Specified in Schedule x* and / or drugs other than those specified in Schedule ¢,c(1) and x to the brags and Cosmetics Rules, 1945' end also to operate a pharmacy on the ae sptuated at 8/45. =. opp:.MPDO,...OfFice.. MET. ee puja chittoox.. 2. § The sale and dispensing of drugs will be made under the personal supervision of the registered pharmacist / competent person nemely: - HR: Modlauat ....quaritication....8: pharmacy. apis. UCOR A: AL. . nore: 25-08-2002 J + Categories of drugs to be sold under 20 and 21 / aop-ene-238 4, tParticulars for special storage accommodation 1. LG Les. 2. Aircoller ich 2b or: gees BRIS IO. IESE credited to the Government under the head of account .- beon G-Amala signature of Prop./partuerFORM 19 [See Rule $9(2)] Application for grant or renewall ofa licence to sell, stock, exhibit or offer for sale, or distribute drugs other than those specified in Schedule X As. frmala... WWlp..A:. pxakash.. we. RITAVIK...MEDILCALS.. hereby apply for licence to sale by wholesale/retail drugs specitiea in Schedule € and C(1) and excluding those Specified in schedule x" and / or drugs other than those specified in schedule ¢,c(1) and X to the Drugs and Cosmetics Rules, 1945* and also to operate = pharmacy 1. T/We.. Tee opp. Mppo.. office, MET. Roe, epeegcew ae chittoon.. 2. $ The sale and dispensing of drugs will be made under the personal supervision of the registered pharmacist / competent person namely: ~ wane... KR: Medhurt....cusriticatton.. Pe: phosmacy... apn IT ROCK. [AL cave. 265.0% 22> 3. Categories of drugs to be sold under 20 and 21 /-a98-anc-21m 2, Aircolier Pe ee ene credited to the Goveranest under the head of account G-Prnala Date: Signature of PrDOCUMENTS 7 DECLARATION OF THE PROPRIET net MRECTOR J REGISTERED PHARMACIST 7 COMPETE PI 2S0t1 Shop Name ithvik,. 1. Shop Nam Rett all 2. Full Name (Block Letters) 1G. Ammala. | %xss oer SIZE PHOTO 3. Fathersimtusands name: A. pF akash and his profession 4. Age cae 5, Permanent Address 228-136, kothapeta , Punganuy (Proof to be attached) 6. Present Residemiat address: DO with Contact tel/cell number 7. Educational Qualification : Tnter 3. Detalls of Cartier Orcupetion = For last five years 9. Whether You / Your Spouse are in possession of any Licences under Drugs and Cosmetics Rules Cartier of Present ? If yes, Detals : NO 10. Whether at any time Your / Your Spouses Deug Licences @ Cancelled? If yes, Detaits > NO 11, Whether You / Your Spouse at any tine convicted under any Criminal lav ? if yes, Details No _ 12, Elther alone or with any body, ‘You / Your spouse invelved in any Drug Cases ? if yes, Detalls No 33. Are You /Your spouse convicted / ‘Acquitted in any Coses Under Drugs and Cosmetic Act, 19402 If Yes, Detaits 5 into “T4. Are you studied the Rules ond a in case if any abe Regulations of Drugs and Cosmetics Act, 1940 and Rules 1945 and under-Stand Respareisiues ofa Ucancad Dealer? Y CS Certified that the above information furnished by me 1 tn 2 stated information is found to be tals ea by the officers of the Drugs, Con and correct and vhable for Criminat ‘ot Administration, Anahra somATURE Gg1N-AP779000619070311N felssued Date | OF Ap-2026 02:50PM Foerda NEWIMPAGC (6¥} sp16Q00404/ AP-CTAY AP-CHT/apanukahus ‘1012908001 JT SAO CHETTCOR (9.0) Rotérenes > SURIN-APAPLanananaea7atans42406W GAMA Prop Basciplon Consideration Price. Feet ary 5 GAMA Second Pary ‘Not Appice Paid By (Far Wher) GAMMA tap Duty Anouri(Fs) a = AN (Twonty ony) L 4 R.No. 10-11-007 of 2024 to 2828, « COURT CONPOUND,CHITRCOR: CELL 9177741230. ARPIDAVIT. (Declaration of Proprieto®). eee : I,G.AMALA, age about36 years Wife of A.Prakash,Hindu, residing at D.No,28-136 Kethapeta, Punganur Town, Punganur Post and Mandal,Chittoor Dist.AP ( Aadhaar Card No,9007 3552 0029 and Mobile No.9676639575) do hereby declare for information of the Drug Controlling Authority that I am the Proprietor of M/S RITHVIK MEDICALS, D.No.27-48/45-1, Opp. to PDO's Office, M,.B.T,Road, Punganur Town, Punganur Post and Mandal, Chittoor Dist., I have applied for grant of/change of constitution of the Drug Licences in Yorms 20 and 21 in the above named shop to the Drug Controlling Authorities. ~ GramMala ontd..0..2.. * 00042338112 I further submitted that if any information given by me are found to be false or wrong and the documents submitted by me are found to be false or wrong, I have no objection to cancel our Drug Licences without any notice/ enguire ang that we are also liable for any action ‘mk taken by the Drug Controlling Authorities or Government authorities agat’; against me. A Gamal My Specimen Signatures. SIGNATURE OF PROPRIETOR. th &-Amoala 2 &.amala Fre AMAA ati id Pos & ‘enc Shor DLA, ‘Cai SosgedagaR 122 esi thevenspal a 4& Post & Sandal Chittoor (Dt! AP. Cell: 995994403"