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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:
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
Signature
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
Signature
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)
-do-
NO
NO
Form
Number
20/20A
21/21A
20B/21B
20C/20D
License
Number
Date of
issue
----
------
NO
NO
NO
Fridge provided
AC
-
PHARMACY
YES
NO
Name
Employed
Cert/Reg.
number
Validity
LIFE
8 Hours
NO
NO
YES
Station:
Date:
NAME
REG. NO.
RES. ADDRESS
PREVIOUS
EMPLOYED
AT FROM TO
Station
Date .
:
:
BIO-DATA
1.
2.
3.
4.
Residential Address
5.
Permanent Address
6.
-do-
Class Studied
7.
Course Studied
8.
Professional Experience
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
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:-
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.
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.
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.
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.
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