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(Registered pharmacists)

Affidavit
(On Rs 20/- stamp paper)

I, Sri. /Smt. S/o, D/o, W/o Sri


Aged about years and residing at
do solemnly affirm and state on oath as follows.

I, have passed my Diploma/Degree in Pharmacy Examination


vide Certificate No in the year from ..
Board/University and I am a registered Pharmacist vide
Karnataka State Pharmacy council registration certificate
No dated.

I have accepted to work as pharmacist at M/s


situated at Except this firm, I am not
working elsewhere as pharmacist nor am I continuing
further studies. I will be present throughout the working
hours of the firm and supervise sale of schedule drugs.
Further, if I were to leave the firm for any reason, I
will inform the Assistant Drugs Controller and licencing
authority circle.

Place: Deponent
Date:

Identified by me
Advocate
No. of corrections: Notary
(COMPETENT PERSON)
AFFIDAVIT
on Rs 20/- stamp paper)

I, Sri./Smt. S/o, D/o, W/o Sri


Aged about years and residing at
do solemnly affirm and state on oath as follows:

I had passed S.S.L.C/Degree Examination held during the


year and having register No

I was working in M/s (mention


address)from (Date) to (Date) and thereby
gained satisfactory knowledge in dealing of drugs.

I have accepted to work as competent person at


M/s situated at Except this
firm, I am not working elsewhere as competent person /
neither pharmacist nor I am continuing further studies. I
will be present throughout the working hours of the firm
and supervise sale of the drugs. Further, if I were to
leave the firm for any reason, I will inform the Assistant
Drugs Controller and licencing authority circle.

I abide to follow Rules as per Drugs and Cosmetics Act


1940 and Rules there under.

I declare that the above statements are true and correct.

Place: Deponent
Date:

Identified by me
Advocate
No. of corrections: Notary
(APPLICANT)
AFFIDAVIT
(On Rs 20/- stamp paper)

I, Sri./Smt. S/o, D/o, W/o Sri


Aged about years and residing at
do solemnly affirm and state on oath as follows:

I am the sole Proprietor partner/ Director/Authorized


Signatory of M/s (Mention
address).
I have taken the premises for rent situated at No.
(Place where medical shop is situated)
from (Owner of
the building)

I declare that the measurement of the Shop premises


measures sq. meters. It is commercial in nature

I have submitted the relevant Khatha extract, Tax Paid


Receipt for the same.
I further declare that I will not alter or reduce the area
of premises on my/our own or on order of any authorities,
or if any dispute areas regarding commercial nature of the
premises, I will surrender the drugs license.
I am making this affidavit to make an application to
obtain drug license from Assistant Drugs Controller and
Licensing Authority.

What is stated above is true and correct to the best of my


knowledge and belief.

Place: Deponent
Date:

Identified by me
Advocate
No. of corrections: Notary
(Biomedical Waste)
AFFIDAVIT
(On Rs 20/- stamp paper)

Sri/Smt. s/o or W/o or


D/oagedyears residing at
do solemnly affirm and state
on oath as follows:

(1) I am the proprietor/partner/Director/Authorized sig


of M/s. I will be responsible for
the day-to-day conduct and business of the above firm

(2) I/we, abide to dispose date expiry drugs/Discarded


medicines /un-used medicines/Returned Medicines, As
per Biomedical Waste (Management & Handling) Rules,
1998.

(3) I/we will dispose off date expiry drugs/Discarded


medicines/Un-used Medicines/Returned Medicines as per
Bio medical waste (Management & Handling) Rule 1998
and I/we will abide to protect Environmental
pollution.

(4) I/we, declare that I/we maintain all the necessary


records of Date expiry drugs etc and produce to the
Drugs Inspector on demand.
I am making this affidavit to obtain drugs licenses
from licensing Authorities.

Whatever is stated above is true and correct to the


best of my knowledge and belief.

Place: Deponent
Date:

Identified by me
Advocate
No. of corrections: Notary