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Application for Grant of License to sell, stock or exhibit for sale or distribute drugs (Retail Qualified / Wholesale)
License Type
Select
Wholesale
Retail
Field is required
Category of Drugs (Select only applicable)
Schedule C
Schedule C(1)
Schedule X
Other
Required! Select a category
Name of the Sales Premises / Pharmacy
Field is required
Particulars of storage accomodation
Field is required
Address / Location
Field is required
City
Field is required
Pin Code
Field is required
District
Select
Bishnupur
Chandel
Churachandpur
Imphal East
Imphal West
Jiribam
Kakching
Kamjong
Kangpokpi
Noney
Pherzawl
Senapati
Tamenglong
Tengnoupal
Thoubal
Ukhrul
Field is required
Proprietor Details
Name
Field is required
Father's Name
Field is required
Qualification (minimum XII passed)
Select
12 Passed
Graduade
Master
PhD
Field is required
Date of Birth
Field is required
Sex
Male
Female
Field is required
Mobile No
Field is required
Email
Field is required
Proprietor Address
Field is required
City
Field is required
Pin Code
Field is required
Qualified Person Details
Name
Field is required
Father's Name
Field is required
Qualification
Select
Diploma in Pharmacy
Bachelor in Pharmacy
Master in Pharmacy
PhD in Pharmacy
Field is required
Date of Birth
Field is required
Sex
Male
Female
Field is required
Mobile No
Field is required
MSPC Regd No
Field is required
Address
Field is required
City
Field is required
Pin Code
Field is required
Please check the checkbox below if the you have a license but not process online. You don't have to refill the application form for every renewal if you have submitted one in previous.
This form is for renewal of my license but not yet registered online.