Madhya Pradesh State Co-operative Jan Aushadhi Marketing Federation s Scheme. Application for opening Jan Aushadhi Pharmacy at

Transcription

1 Madhya Pradesh State Co-operative Jan Aushadhi Marketing Federation s Scheme Application for opening Jan Aushadhi Pharmacy at Passport Size Photograph S NO Particulars Details 1 Name of Applicant 2 Status of Applicant Individual entrepreneur (Tick Appropriate Box) Charitable Institute/Hospital NGO / Trust Government/ Government Nominated Agency 3 Registration Number of Organization, Date of Incorporation (if Applicable) 4 Name of Contact Person Any Other (Please specify) Designation Mobile No/Landline No id 5 Aadhaar Card Number 6 PAN Number 7 Location of the Proposed Store with Complete Address Declaration: 1. I have gone through the terms and conditions as mentioned in the guidelines for opening of Jan Aushadhi Pharmacy and agree to abide by the same. 2. I/We hereby declare that all the information as mentioned above is true to best of my knowledge. If any information is found to be incorrect, my/our candidature is liable to be cancelled and may be subject to legal/disciplinary proceedings. 3.Supporting documents are attached wherever required for information as provided above Page 1 of 5

2 Date: Place: Signature Name and Designation Note: Applications without Aadhaar Card shall be summarily rejected. List of documents required to be attached with application Individual Institutions/NGO/ 1. Aadhar Card Charitable Institute/Hospital etc. 2. Pan Card 1. Aadhaar Card 2. Pan card 3. Certificate for Incorporation 4. Registration certificate Government/ Govt Nominated Agency 1. Details of Department who has allocated the space, along with supporting documents/ sanction Order. 2. Pan Card 3. Aadhar Card 4. Registration Certificate Page 2 of 5

3 For Individual entrepreneurs/ Institution who are already running a Pharmacy/ Medical Store and want to convert it into Jan Aushadhi Pharmacy. 1. Complete Address along with landmark of your Pharmacy/ Medical Store s Location. 2. Why do you want to convert your existing Pharmacy/ Medical Store to Jan Aushadhi Pharmacy. 3. Is it a Private Pharmacy/ Medical Store or a Franchisee store/ PMBJP store? 4. The store has been operational for how many years? 5. What all products are being sold at your store? 6. Do you have a valid retail drug licence for your store? If Yes the what is the validity of the licence. 7. Is you Retail Drug Licence in the name of an individual or an organization e.g. PMBJP.

4 8. What is the size of your store? kindly specify the size in Sqft. 9. kindly share the following pictures of your store. a) Front Counter. b) Front Road Access to your store. c) Storage and other Infra. d) Computer & Printer e) Refrigerator for cold chain products. 10. What is the average daily and monthly sale of your Pharmacy/ Medical Store? 11. How employees do you have in your Pharmacy/ Medical Store. 12. What are the working hours for your Pharmacy/ Medical Store? 13. What is the commercial value of the stock currently available at you Pharmacy/ Medical Store? 14. Are there any legal formalities that you need to complete with your Franchisor organization before you can convert the store?

5 15. If your answer is Yes for question Number 1, then how much time is required to complete those formalities?