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From

Date :27/11/15

To,
THE ASSISTANT DIRECTOR OF DRUGS CONTROL
KANCHEEPURAM ZONE, CHENNAI-6
Respected Sir,
We are herewith submitting all the particulars with application for the FRESH
DRUG LICENSE in Form 20&21. We request you to kindly do the needful for our drug
licenses.
Thanking you.
Yours faithfully

Enclosures:
1. Form 19 2- Nos. (Rs. 4/- Court fee stamp affixed)
2. Declaration Form
3. D.D for Rs. 3000/- vide D.D. No.

/SBI, Ch-

Dated:

4. Copy of rental agreement obtained from the Owner of the building


5. Legal Tenancy affidavit in Rs. 20/- Stamp paper
6. Pharmacist Affidavit in Rs. 20/- Stamp paper
7. Copy of Pharmacist Certificate
8. Bio-Data with photo of Proprietor& Pharmacist
9. Building property tax copy
10. Blue Print
11. Refrigerator & AC Bill copy

The Drugs & Cosmetics Act, 1940 and rules 1945


FORM 19
[See Rule 59(2)]
Application for the Grant/Renewal of license to Sell, Stock (or offer) for sale or Distribute Drugs other than those
specified in Schedule X.

I/We
PROPERITOR of SMART VISION AND DIABETES CLINIC, 115, KAMARAJAR
AVENUE 2ND STREET, ADYAR, CHENNAI 600 020
Here by apply for a license to sell by Wholesale/Retail drugs specified in Schedule C
and C(1) excluding those specified in schedule X* and / drugs other than those specified in
Schedule C and C(1) and schedule X to Drugs and Cosmetics Rule, 1945 and * also to
operate a pharmacy on the premises, situated at

1. The sale and dispensing of drugs will be made under the personal supervision of a
qualified persons mentioned below.
Name: D. THATCHAYANI

Qualification: D.Pharm

2. Categories of drugs to be sold


All Drugs other than those specified in Schedule C and C (1) and excluding those
specified Schedule X to the Drugs and Cosmetics Rule, 1945
3. Particulars of storage accommodation for Schedule C and C (1) drugs in the
premises referred to above.
Fridge provided 1
AC
1
A fee of Rupees One thousand and five hundred only has been credited in the Govt. account
vides demand draft.
Date:

Signature

* Delete whichever is not applicable


* To be deleted if drugs will be sold only by wholesale
** required only if products requiring special storage are to be sold.

The Drugs & Cosmetics Act, 1940 and rules 1945


FORM 19
[See Rule 59(2)]
Application for the Grant/Renewal of license to Sell, Stock (or offer) for sale or Distribute Drugs other than those
specified in Schedule X.

I/We
PROPERITOR of SMART VISION AND DIABETES CLINIC, 115, KAMARAJAR
AVENUE 2ND STREET, ADYAR, CHENNAI 600 020
Here by apply for a license to sell by Wholesale/Retail drugs specified in Schedule C and
C(1) excluding those specified in schedule X* and / drugs other than those specified in
Schedule C and C(1) and schedule X to Drugs and Cosmetics Rule, 1945 and * also to
operate a pharmacy on the premises, situated at

4. The sale and dispensing of drugs will be made under the personal supervision of a
qualified persons mentioned below.
Name: D. THATCHAYANI

Qualification: D.Pharm

5. Categories of drugs to be sold


All Drugs specified in Schedule C and C (1) excluding Schedule X to the Drugs
and Cosmetics Rule, 1945
6. Particulars of storage accommodation for Schedule C and C (1) drugs in the
premises referred to above.
7. Fridge provided
AC
8. A fee of Rupees One thousand and five hundred only has been credited in the Govt.
account vide demand draft.
Date:

Signature

*Delete whichever is not applicable


*To be deleted if drugs will be sold only by wholesale
** required only if products requiring special storage are to be sold.

DECLARATION FORM
(This must be filled in and returned to the Assistant Director of Drugs Control along with application form):
(Note: No column should be left blank or with a dash. If you have no particulars to furnish for any application is
made. Nil Does not Arise should be entered)

1. Name and complete address of the


Firm for which application is made,
2. Names(s) and residential address (es)
of the proprietor / all partners /
Directors / Manager
3. Applicants previous occupation
4. Applicants present occupation

-do-

5. Applicants experience, if any


In Drugs trade
6. Is the application for fresh
License or renewal

FRESH licenses in Form 20/21

7. Was there any change in the


Proprietorship / Partnership of
The concern since the issue of
Previous licenses and if so,
from what date?
(A true copy of sale deed should be sent)
8. Was there any change in the premises of the
Concern since the issue of previous licenses
And if so, from what date

NO

NO

9. Particulars of licenses held by the


Applicant in respect of premises
For which the present application
Under is made Drugs & Cosmetics Act

Form
Number
20/20A
21/21A
20B/21B
20C/20D

License
Number

Date of
issue

----

------

10. Addresses of other premises where the


Drugs are stocked or sold or office is
Maintained by the applicant. The Drug
Licenses number, Form of license and
Date of issue of each license pertaining
To the above should be stated.

NO

11. What category the firm come under


a. General Merchant
b. Chemists and Druggists
c. Pharmacy.
d. Wholesale Dealer (Mention
The names of the company)
Importers (Mention the name of
The country, Drugs to be imported)
e. Distributing Agency (state the
Name of the Manufactures for
Whom you are the distributor or
Agency and furnish a true copy of
The agreement)
12. Is there a separate cupboard or
Drawer reserved solely for the
Storage of Schedule X drugs?
13. (a) Nature of cold storage provided:

NO

NO

Fridge provided
AC
-

(b) Whether it is working condition


14. If running a pharmacy whether the
Requirements of Schedule N to the drugs
Rules have been provided
(A list of equipment and books available
Should be enclosed)
15. Particulars of qualified persons(s)

PHARMACY

YES

NO

Name
Employed

Cert/Reg.
number

Validity
LIFE

16. Hours of business and working days

8 Hours

17. Have you ever convicted under the


Drugs Act or any other Act?

NO

18. Was the application ever rejected or


Cancelled previously or suspended or
Surrounded

NO

19. Are you the legal tenant of the premises


Occupied by you

YES

I declare that the above statements are true.


I further declare that I am conversant with the provisions of the Drugs Act, 1940
and the Drugs Rule, 1945 and I will abide by the conditions of the licenses.

Station:
Date:

Signature of the applicants

Declaration of the Pharmacist


I hereby declare that I employed in the above firm as full time qualified person and not
employed anywhere else and submit the details of the previous employments.
SL.
NO.

NAME

REG. NO.

RES. ADDRESS

PREVIOUS
EMPLOYED
AT FROM TO

Station
Date .

:
:

Signature of Qualified Person

BIO-DATA
1.

Name of the Applicant

2.

Age, Date of Birth

3.

Son of / Daughter of/ Wife of

4.

Residential Address

5.

Permanent Address

6.

School at which studied

-do-

Name & Address of the


School

Class Studied

7.

College at which Studied

Name & Address of the


College

Course Studied

8.

Professional Experience

Name & Address


of
The Institution
where served

Period

Post Held

Period of Studied

Period of Studied

Reason for
Leaving

9. Whether the applicant ever holding the Drugs Licenses? If so details.-NA10. Whether the applicant family members ever holding the Drugs Licenses?
If so Details.
- NA
11. Specimen Signature
1.
2.
3.
The details above furnished are true to the best of my knowledge.

Place:
Date:

Signature of Applicant

PH

2015 25 6, , 2 , ,
-100 J. SERAPHINE
JOYCE
. 12207 A1 .
25-10-2015 12207 A112207 A1J.K. MEDICALS 5/11, -1,
, , , , -73 .
,

.
,

.
endorsement
.

OW


-59, , , -2- .

28/10/15 ,
J.K. MEDICALS 5/11, -1, , , ,
, -73
.
. ,
. ,


2015 11 , -73, , 5/11,
-1, , , , .. . D.
( )
-59, , , -2- .
( )


1. 5/11, -1, , ,
, , -73 , J.K.
MEDICALS ,
.
-22. 2,00,000/- ( )
.
.
3. 4000/- .

4. 60 (11/11/15 10/11/2020)

..
5. 2 .
6.
3 .
7.

1.

Supporting Documents:
1.Copy of Shop Property Tax receipt - current year 2014-2015
2.Copy of Owner Pan Card or Pan applied (Acknowledgement) copy
3.Copy of Owner Address Proof
4.Copy of Shop Tax Demand Card
5.Copy of Shop EB Card

RENTAL AGREEMENT

THIS RENTAL AGREEMENT EXECUTED AT CHENNAI ON this the 1ST day of


November 2015 by and between
Mr. D. Sundaramurthy, S/o Duraisamy , Hindu, aged about 70 years residing at
No.5/11, Ganesh Nagar Mian Road, Gandhi Nagar, Selaiyur, Chennai-600 073,
hereinafter called the LESSOR which terms wherever occurs shall mean and
include their respective legal heirs, representatives, administrators and assigns on
ONE PART.

Lessee

Lessor

AND
Mrs. J. Nithyaowner of M/s. J.K. MEDICALS residing at No. 2-B, ANNAI SIVAGAMI
STREET,SELAIYUR, TAMBARAM, CH-59 aged about 24 years, hereinafter called the
LESSEE which term wherever occurs shall mean and include all its Partners, their
successors in office, the legal representatives of the firm, executors, administrators and
assigns on the OTHER PART WITNESSESTH AS FOLLOWS:

Whereas the LESSOR is the absolute owners and in possession of the Property
namely Shop, Ground and Premises bearing Shop No.5/11, Ganesh Nagar Mian
Road, Gandhi Nagar, Selaiyur, Chennai-600 073,. The Lessor is paying the Property
Tax and other taxes to their above said property regularly.
Whereas the LESSEE is doing and dealing pharmaceutical retail/wholesale business
by running medical shop.
Whereas the Lessee approached the Lessor and requested them to let out the Ground Floor
Shop Portion measuring to an extent of about 270 Sq.Ft in the above said property,
(carpet area measuring 220 Sq.Ft) herein after called the Lease Portionmorefully
described in the Schedule, for their pharmaceutical Business purpose. Whereas the Lessor
have also agreed to let out the Lease Portion to the Lessee and the Lessee has also agreed to
take the Lease portion on monthly Lease rent.

The Lessor and the Lessee have mutually discussed the matter and agreed on the following
terms and conditions and thought it prudent to reduce the same into writing:-

General Covenants of Both the Lessor and the Lessee:


BOTH THE LESSOR AND THE LESSEE HAVE AGREED FOR THE FOLLOWING
COVENANTS:
1. LEASE PREMIUM, CAUTION DEPOSIT AND MONTHLY LEASE RENT:
The Lessee has paid a Sum of Rs. 5,00,000/- (Rupees FIVE lakhs only) as refundable
Caution Deposit to the Lessor herein by way of a Cash to the Lessor and the receipt of the
above sum of Rs. 5,00,000/- (Rupees Five lakhs only) is hereby admitted and acknowledged
by the Lessors.
The Lessee hereby agrees with the Lessor that the above said sum of Rs. 5,00,000/- (Rupees
Five lakhs only)SHALL NOT CARRY ANY INTEREST and the same will be returned to
the Lessee by the Lessor, ONLY at the time of handing over the vacant Lease portion in
good condition, after deducting rent and maintenance arrears, if any.
The Lessor hereby agree that they will pay interest @ 24 % per Annum on the refundable
Security Deposit amount from the date it is due and payable by them to the Lessee, if they
are unable to repay the Security deposit amount for any reason and the Lessee shall be at
liberty to continue in the lease premises till the date the said refundable security deposit is
repaid to the Lessee and no rents shall be payable in respect of the lease premises for the
period from which date the caution deposit becomes payable to the Lessee.

Further the Lessor and the Lessee have agreed that the monthly Lease rent towards the
Lease portion is Rs. 10,000 /- (Rupees Ten Thousand only). The Lessee has also agreed with
the Lessor that the Monthly Lease Rent shall be paid to the Lessor on or before 10 th day of
every succeeding English Calendar month. It is further understood and agreed between the
Lessor and Lessee that the rental amount is inclusive of all applicable taxes including
Service tax, cess etc., in respect of the Lease premises, whether payable presently or in
future.
The Lessee shall deduct the TDS ( Tax Deduction at Source) from the rent as per the
provision of Section 203 of the Income Tax Act 1961.
2. INCREASE IN LEASE RENT:
The Lessor can increase the monthly Lease rent of the Lease portion after every

2 Years

at the rate of 10%(Ten) percent on the existing rent, such increase shall be after the
completion of every three years of lease and on the last monthly rent paid.
3. COMMENCEMENT OF LEASE:
This Lease is for a period of 5 Years only commencing from today i.e., from the date
execution of these presents. Further the Lease is reckoned according to English Calendar
month. After the completion of the said period, the lease shall be renewed on mutual
understanding between both the parties.

4. SUB-LEASE OR SUB-LETTING:
The Lessee shall not sub-let the lease portion to any other third party except with the prior
permission of the Lessor.

5. STRUCTURAL ADDITIONS AND ALTERATIONS:

The Lessee shall not effect any structural additions and alterations, which are permanent
in nature to the Lease portion without the written consent of the Lessor. But the Lessee can
do interior decoration to the Lease Portion as per the requirements of their business and
can fix cupboards and A.C fittings to the lease Portion, but shall remove the same at the
time of vacating the lease portion and further shall hand over the lease portion in the same
condition as it is today.
6. PURPOSE OF LEASE:
The Lessee shall utilize the Lease portion only for their Pharmaceutical business purpose
and for other allied business, if any, under the name and style of J.K. MEDICALS or any
other name as they deem fit. But the Lessee shall not store any materials prohibited by any
law. The Lessee shall not use any machinery in the lease portion wherein creating
disturbing noise or vibration to other tenants.

7. PAYMENT OF AMENITIES AND OTHER CHARGES:


The Lessee should pay the electricity charges according to meter reading of the Electricity
Board regularly. keeping the Lease portion in good condition. The lessor shall pay relevant
business taxes.

8. PROPER AND REASONABLE CARE TO BE TAKEN BY THE LESSEE:


Further the Lessee should keep the Lease portion is good condition during the subsistence
of lease. The Lessee should not do any act of waste wherefrom the materialistic value of the
Lease portion is diminished. Further the Lessee is liable to pay for any breakage and
damages to electrical fittings, sanitary fittings and other fixtures and fittings during the
period of Lease in the Lease portion, natural wear and tear is exempted.
9. AUTHORISATION FOR INSPECTION OF LEASE PORTION

The Lessee further agrees that the Lessor, that his/her family members and their
authorized persons can inspect the Lease portion by giving due notice and at reasonable
times and the Lessee should not object to that.
10. TERMINATION OF LEASE:
1. Notwithstanding anything contained in this Lease Deed, if the Lessee commits default in
payment of monthly Lease Rent for consecutive Three months, this lease shall be
terminated automatically, provided the Lessor shall notify the termination of lease to the
Lessee in writing..
2. Notwithstanding anything contained in this Lease Deed, the Lessee shall give Three
months notice in advance to the Lessor at the above address in the event the Lessee
intents to vacate the Lease premises and the Lessor agree to the same and shall
permit the Lessee to vacate the property without any objection or hindrance from
the lessor or anybody representing them.
11. JURISDICTION.
The Courts in Tamil Nadu, which have jurisdiction over the area in which the Lease
Portion is situated, shall have the Jurisdiction.

EXPRESS COVENANTS OF THE LESSORS:


The Lessor hereby expressly covenants with the Lessee that during the lawful subsistence
of this lease, the Lessee shall be entitled to peaceful possession and enjoyment of the lease
portion. Further the Lessor has handed over the vacant Possession to the Lessee at the time
of execution of these presents and the Lessee has also taken Vacant possession of the Lease
portion from the Lessor
The Lessor hereby covenant that they shall not commit any act, deed, matter or thing
during the period of Lease where by the Lessor right to lease or the Lessees right to use the

lease premises is jeopardized, affected or otherwise rendered void. The Lessor agree to
keep the Lessee indemnified against any or all such Acts and Deeds.
Further the Lessor undertake to give necessary Letters to the concerned Government
Authorities in order to enable the Lessee to obtain proper License for running their
Pharmaceutical Business.
Further the Lessor undertake to give proper receipts to the Lessee for the lease rents
received without any delay.
EXPRESS COVENANTS OF THE LESSEE:
The Lessee hereby expressly covenants with the Lessor that they shall run their
Pharmaceutical Business as per the procedure laid down by the concerned Law applicable
to their trade and further declare that they shall not deal, store, sell in medicines and
pharmaceutical preparations which are not allowed in law.
The Lessee further expressly covenants with the Lessor that they shall adhere to the terms
and conditions of these lease deed in letter and spirit and shall not commit any breach of
the same.

SCHEDULE OF THE LEASE PORTION


A Shop Portion in the Ground Floor, measuring to an extent of about 270

Sq.Ft

(Carpet Area measuring 220 Sq.Ft) in the Property bearing No.5/11, Ganesh Nagar
Mian Road, Gandhi Nagar, Selaiyur, Chennai-600 073,
East

West

North :
South :

IN WITNESS WHEREOF THE LESSORS AND THE LESSEE HAVE AGREED AND
SIGNED ON THE DAY, MONTH AND YEAR ABOVE WRITTEN IN THE PRESENCE
OF:
WITNESSES:

1.

LESSOR

2.

LESSEE

COMPETENT AFFIDAVIT
D. THATCHAYANI declare & solemnly affirm the following to the Licensing
Authority, THE ASSISTANT DIRECTOR OF DRUG CONTROL, CHENNAI Zone III
Chennai-6, on 16 August 2016.
I will look after the day to day activity of the business of the said firm & I am fully
aware of provisions of Drugs and Cosmetics Act 1940 & Rules 1945 and I am responsible
for any contravention thereof. I will maintain the sales bills, purchase bills for drugs &

maintain all required records and registers of the firm as stipulated under the Drugs and
Cosmetic Act 1940 and rules 1945.
If I leave the said firm, I will inform the licensing authority of my resignation and
this affidavit to be treated as cancelled from the date resignation.
Place : adyar
Date

: 16/08/2016
SIGNATURE