If you want to register your pharmacy certificate in Mumbai or around the state of Maharashtra you need to apply for the registrant as new applicant at Maharashtra State Pharmacy Council. We provide you here Pharmacy Registration Application Form PDF Download to apply for pharma Registration.
(See Rule 56)
FORM OF APPLICATION FOR REGISTRATION OF PHARMACISTS
(UNDER SECTION 33 OF THE PHARMACY ACT, 1948)
|For office use||To be filled in by office||For office use|
Date RR No ARFL R No PPP R No
DIB R No Sign
NO-N/_ is registered u/s 32(2)
MAHARASHTRA STATE PHARMACY COUNCIL ,
E.S.I.S. Hospital Compound L.B.S. Marg, Mulund (West), Mumbai – 400 080.
E mail:[email protected] Dear Sir/Madam
I request that my NAME, ADDRESS AND QUALIFICATIONS as stated in the accompanying form may be registered under the Pharmacy Act, 1948, and that same may be furnished with a Certificate of Registration.
I enclose herewith for your perusal and return the certificates and diplomas in original and their copies for the record. The requisite fees as required under rules of the Maharashtra State Pharmacy Council Rules, 1969, is remitted in the office (as per the annexure). I hereby declare that I have read the provisions of Sec. 32(2) and 41 and all relevant provisions of the Pharmacy Act, 1948; I have myself filled the application form and all the entries in the form are true to the best of my knowledge and belief.
Date: Name: Signature:
In continuation of above, in conformity with MSPC Rules 1969 (Rule NO- 57(2) ) I hereby voluntarily remit and request you to please accept the amount of Rs. _ (Rs.
) as Advance Renewal fee in lump sum (ARFL) from me, paid in order to avoid difficulties arising out of my inadvertent failure to pay the renewal fees every year in time.
In future, if due to some reason this amount becomes inadequate to cover my renewal fees, I shall be glad to remit such additional amount as you may deem fit.
In the event of conclusion of my registration on account of one of the following reasons, this amount of ARFL shall be treated as my donation to the council as per Rule 82 of MSPC Rules-1969 and I assure you that neither me nor my nominee or representative will claim for any refund of same from council.
1) Transfer or migration to other state 2) Cancellation of registration on account of my death,
- Voluntary submission of Registration Certificate to council for practicing some other profession or other reason
- Temporary or permanent cancellation of registration under section 36 of the Pharmacy Act-1948
I will inform you my residential or professional address if there is any change in the same.
I am also fully aware of the directives of the Pharmacy Council of India, New Delhi regarding compulsory attendance of at least two refresher courses (Continued education program) in five years duration for further renewal of my registration.
I also understand that Pharmacist’s Professional Profile is supplementary to Registration Certificate issued by Maharashtra State Pharmacy Council and this may be used as authorized proof of Identity. I also voluntarily remit necessary charges towards the publications and bulletin published by Council’s Drug Information Centre during this financial year.
I hereby declare that I have read and understood everything mentioned above and agree with same and will abide by it, I request you to make me participate under ARFL scheme and Pharmacist’s Professional Profile.
Signature (sign here)
The name entered in application form must correspond with the name of the applicant entered at the university or other examinations certificate.
- 1. Name in full, beginning with Surname Surname (In block Capitals)
Name Father’s/Husband’s Name
Old Name (if any)
2 Date of birth _ 3) Nationality
4) Male / Female 5)Place and District of birth
- Residential Address in BLOCK letters
(Should include House NO., Street name, Village, Town, Taluka, Dist and Pin code)
- Permanent Address :
_ Taluka _ District _ Pin
- Present/Correspondence Address :
_ Taluka _ _ District Pin _
Residence Telephone No. _ _ Mobile No. _
- Address of business or profession :-
- Description of Qualification of which registration is desired along with documentary evidence.
|Qualification||Year||Institute/College Name in full||Date of Passing
|1st Year||1st Year|
|2nd Year||2nd Year|
|Additional Qualification(if any)||Year||Institute/College Name in full||Date of passing (dd/mm/yyyy)|
Signature of the Applicant
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