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APPLICATION FOR DCO/BCO

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ORGANIZATION/INSTITUTION PROFILE
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01. Name of the Organization/Institution:


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02. Year of Establishment: (Please Attach Proof)


स्थाऩना वर्ष ( )

03. Type of Organization/Institution: (Please Attach Proof)


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1. Individual Entrepreneur 2. NGO/Society/Trust

3. Pvt. Ltd. 4. Any Other

04. Registration Number of Organization

05. Pan Number

06. Full Postal Address:


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Circle District:
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State: Country:
राज्य Pin Code:

07. Official Communication:


आधधकाररक संचार

Phone No:

(Country Code) (STD/Local Code)
08. Mobile No:
मोबाइऱ नंबर +91

Email:
Fill the Following and Enclosed Proper Proof:
09. Premises Details: Owned Rented
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10. Total Area of Organization/Institution (Sq. Ft):


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11. Internet Connectivity: Yes No


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Please paste Office/Building photo in below box

DIRECTOR PROFILE
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1. Name:
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Passport Size
2. Designation:
Color
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Photograph of
Director
3. Gender: Male Female
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4. Qualification:
:

5. Experience:
अनुभव:

6. Photo ID Proof: (Kindly enclose the copy) Driving License Passport Voter ID PAN Card
( ) ऩासऩोर्ष वोर्र आईडी

7. Aadhar No.
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DECLARATION

1. I/We have gone through the terms and conditions as mentioned in the guidelines for opening of Shri
Aushadhi Ayurveda Kendra and agree to abide by the same and appoint pharmacist for obtaining
drug license (in case applicant is not-pharmacist).

2. I/We hereby declare that all the information as mentioned above is true to best of my knowledge. If
any information is found to be incorrect, my/our candidature is liable to be cancelled and may be
subject to legal/disciplinary proceedings.

3. Supporting documents are attached wherever required for information as provided above

Date: Signature
Place: Name and Designation

Note: Applications without Aadhaar Card shall be summarily rejected.

List of Documents required for opening of Shri Aushadhi Ayurveda Kendra to be attached with Application
Individual Institutions/NGO/Charitable Other:
1. Aadhaar Card Institute/Hospital etc.
2. Pan Card 1. Aadhaar Card
3. Certificate for disability 2. Pan Card
(only for disable 3. Certificate for
applicants) Incorporation
4. Pharmacist Registration 4. Registration Certificate
Certificate 5. Pharmacist Registration
Certificate
Please send application form to Head Office:- Gandhi Bhawan, Roorkee Road, Muzaffarnagar-251001 (UP)
Website: www.shriaushadhi.com, E-mail: info@shriaushadhi.com, Phone: 0132-440022,
Mobile: 9219334455, 9258334455, 9286334455

In any disputes the courts of Delhi shall have exclusive jurisdiction.


,

DATE:
ददनांक

Specimen Signature of the Proposed Principal/Director Seal & Signature of the Head of the Organization

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