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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
Category of Drugs (Select only applicable)
Schedule C
Schedule C(1)
Schedule X
Other
Name of the Sales Premises / Pharmacy
Particulars of storage accomodation
Address / Location
City
Pin Code
District
Select
Bishnupur
Chandel
Churachandpur
Imphal East
Imphal West
Jiribam
Kakching
Kamjong
Kangpokpi
Noney
Pherzawl
Senapati
Tamenglong
Tengnoupal
Thoubal
Ukhrul
Proprietor Details
Name
Father's Name
Qualification (minimum XII passed)
Select
12 Passed
Graduade
Master
PhD
Date of Birth
Sex
Male
Female
Mobile No
Email
Proprietor Address
City
Pin Code
Qualified Person Details
Name
Father's Name
Qualification
Select
Diploma in Pharmacy
Bachelor in Pharmacy
Master in Pharmacy
PhD in Pharmacy
Date of Birth
Sex
Male
Female
Mobile No
MSPC Regd No
Address
City
Pin Code
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.