application of registration pharma licenc
TRANSCRIPT
Application for Registration, , ,
Under section 33 of Pharmacy Act (V[I of 1948)
TheRegistrar,RAJASTHAN PHARMACY COTINCILGovt. Dispensary Campus, SardarPatel Marg,JAIPUR=30200 l, Tel.lF ax : 0l 4l -2228600
Sir,I request that my name be entered in the REGISTER OF PHARMACISTS maintained by the RAJASTHAN
PHARMACYCOLTNCIL, undersection32ofthePharmacyAcll948 (VIII of 1948), andthaton such entryl maybefurnished with a certifi cate of registration.
I have given the particulars required on the reverse, and I declare that they are correct, and that I reside/carry onthe businessorprofession ofPharmacy inthe StateofRajasthan, myaddress beingas given below.
The Prescribed Application fee of .Rs. 1000/- one thousand only is paid herewith vide I.P.O./D.D./Banker
Council.Jaiour'
The undermentioned diplomas/certificates/documents are enclosed in original with one attested Photocopyand itis requestedthatthey be returnedto meonthe disposalofthe case.
' I.sbcoNpeRYSCHooLCERIIFICATE (tutarksheuisnotacceptable)2. SENIOR SECONDARY CEMIFICATE/ Mark Sheet
3.DEGREE/DIPLOMA/PROVISIONAL CritiJi*trituedbyUniversity/Boardasaproofofhavingpassedapproved examination ofPhannacy. (Provisional Certificate issued by college is not acceptable)
4. MARK SHEET ofDegree/Diploma Pharmacy.
5. PRACTICALTRAINING completiontorm in case otD.Phmma Candidates only.6. CERIIFICATE OF REGISTRATION as aPharmacist issued by other State Pharmacy Counc il (with two
attestedphotocopies)7 . ilfuo lotest possport siw PHOTO with name and datu prtnted on it one photo to be affaed on application
lorm.8. AFFIDAVIT in support ofdocuments and other details.9. Latest proofofresiding/carrying on profession or business ofpharmacy in Rajasthan. (Election Photo ID
Catd, Pasqnrt, Driving Licence, Ration Cord etc.)
Bonside resident urtlyiru, t no, admitted as a proof of resident10. I undertake to inform the Registrar, Rajasthan Pharmacy Council, my professional address immediately
aftertakingup employment (as aregisteredpharmacist/competentperson on any druglicence oranyother
To
Yours faithfully
FullName:.....................................
Note : Signature should be same as onpract. Training form & Midavit
Address:
PARTICULARS TO BE ruRNISHID BYTHEAPPTICANT
Name (in block letters)
Residential Address....
Qualification for registration (i) D.Pharma / B.Pharma
(ii) Registered Pharmacist with...... ..."...state Pharmacy Council.
[Year of Passing the D.Pharnra/B.Pharnra with the name of Board/
University or other examination body from which passedl
Employment, if any, Name of the Employer..
Note :It is futy of every Registered Pharmaxist to infonn the Registrar, Rajasthan Pharmacy Councilhis/hcr professional address immediately after taking up employnent (as a registered plwnnacistlCompetent person on any drug licence or any other employment and he/she should also lceep onintorming every change in his/her professional address/employnentlResidential Address.
(Applicant Signoture)
Full Name.
Address......
Dated."
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