Application for Retention of a licence to repack for sale or distribution of drugs, being drugs other than those specified in Schedule C and C (1) excluding those specified in Schedule X Form 24-B

UBIN Details

UBIN *

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Mobile Number *

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Select Office *

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Applicant Details for SMS Notification

Full Name of the applicant *

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Mobile Number of the applicant *

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Section

1. I/We *

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of M/s *

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hereby apply for grant/renewal of licence to repack the following drugs at the premises situated at *

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Section

3. Name, qualification and experience of competent staff *

SlNo.

Name *

Qualification *

Experience *

SlNo.

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Name of the product to be repacked *

Sl no

Name of product *

Sl no

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Section

Licence No.

Issue date

Section

Date *

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Mode of Application Fee Payment *

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