Before the NOTARY PUBLIC AT……………..(Name of place)






I/WE, (i) Sri / Smt. ___________________________________ Son of / Daughter of / wife of ________________________ aged about ____________ years, by occupation ____________,  presently residing at *[and (ii)] same details of other applicants (deponents if any)]  ____________________________________________________ do hereby solemnly affirm and declare as follows: -



  1. THAT, I/we am/are a citizen of India by birth / by registration at ____________________________.

  2. That, I /We am /are not in the employment under Government or any Government institution or Government undertaking organization as on date.

  3. THAT, I/we am/are the Proprietor / Proprietress / Partner / Director of M/s _____________________________ having its address at Holding/Dag No. ____________, Ward No. / Kh. No. _____, J.L. No. ______, Mouza _____, Municipality / Corporation, Vill ____ , P.O. __________, P.S. ________, District __________, Pin Code ________.

  4. THAT, I / we intend to engage Sri /Smt ________________________________________ on whole time basis as a Competent Person in terms of provisions of Rule 64(2)(ii) of the Drugs & Cosmetics Rules, 1945 in my/our said firm M/s _________________________ having its address at _______________ with effect from________,  to supervise the sale, purchase, distribution, storage of Drugs from my / our proposed above mentioned premises.

  5. THAT, Sri /Smt. __________________________ is not engaged anywhere else as a Competent Person or in any capacity in other Firm except my / our Firm and if it is proved to the contrary or false my/our application for grant of Wholesale Drug license is liable to the consequence including rejection and cancellation.                                                                              

  6. I /We further state that to maintain cleanliness and hygenicity, no business / trade / profession other than the trade of medicines / drugs / by me / us or by me / our agent or any other person will be conducted within the licensed premises or in its adjoining space having inter connections with the licensed premises.

    1. That the proposed premises is presently not having any valid Drug License as far as my/our knowledge is/are concerned. That the firm will comply with the rules of  CCE (Chief Controller of explosives).

    2. That I/We know that knowingly furnishing false information to a public servant is a criminal offence of the Indian penal code (IPC) and I/We may be prosecuted by the appropriate authority before and even after issuance of license for such act and my our application for grant of licenses and my /our licenses if already issued, would also be liable to consequences including rejection and / or cancellation.








Verification :-


That  all the statements made above are correct & true to the best of my knowledge and belief.






                                                                                           Identified by me and signed in my presence      



                                                                                     ADVOCATE/_______________Name of place


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