Pharma Dealer Self Declaration Affidavit Template

About this agreement

Affidavit for Self Declaration by Owner as a Pharmaceutical Dealer Format

Are you a pharmaceutical dealer in India seeking a quick and compliant way to submit your self-declaration affidavit for license approval? Our Affidavit for Self Declaration by Owner as a Pharmaceutical Dealer Format is the ready-to-use legal template you need, available in PDF and Word formats for easy download and customization.

This affidavit serves as a crucial self-certification document required under the Drugs and Cosmetics Act, 1940, and Rules, 1945, particularly for obtaining or renewing a drug license from the State Drug Control Authority. It allows the owner to formally declare ownership of the pharmacy or dealership, affirm compliance with regulatory standards, and confirm no disqualifications. Whether you're starting a new retail pharmacy, wholesale drug business, or updating your license, this Affidavit for Self Declaration by Owner as a Pharmaceutical Dealer Format ensures your application is complete and legally sound.

Why is it Important?

In India's tightly regulated pharmaceutical sector, self-declaration affidavits are mandatory for license applications under Form 19, 19A, 20, 21, etc. Failure to provide a properly formatted affidavit can lead to delays, rejections, or penalties. This document verifies the owner's identity, business legitimacy, and adherence to Good Manufacturing Practices (GMP), storage norms, and sales restrictions on prescription drugs. It's especially vital during inspections by the Central Drugs Standard Control Organization (CDSCO) or state authorities, protecting your business from legal disputes and ensuring uninterrupted operations.

Key Elements of the Affidavit for Self Declaration by Owner as a Pharmaceutical Dealer Format

A professional Affidavit for Self Declaration by Owner as a Pharmaceutical Dealer Format includes:

Personal Details: Full name, address, contact information, and identification proof of the owner/declarant.
Business Information: Pharmacy name, address, license number (if existing), and type of dealership (retail/wholesale).
Ownership Declaration: Sole proprietorship statement, confirming no partnerships or disputes.
Compliance Statements: Affirmations on qualified staff (registered pharmacist), proper storage, no sale of banned drugs, and record-keeping as per Schedule M.
No Disqualification Clause: Declaration of no convictions under drug laws or other disqualifying factors.
Verification and Attestation: Signed before a Notary Public or Oath Commissioner, with date and stamp.

These elements make the affidavit court-ready and authority-approved.

Who Should Use It?

This legal template is ideal for:

New pharmaceutical dealers applying for their first drug license.
Existing owners renewing licenses or transferring ownership.
Wholesalers, retailers, and hospital pharmacies in compliance with state FDA requirements.
Businesses in civil or commercial contexts needing self-certification for tenders or partnerships.

Common use cases include license applications in Maharashtra, Delhi, Karnataka, and across India.

Download Your Customizable Affidavit Today

Get instant access to our Affidavit for Self Declaration by Owner as a Pharmaceutical Dealer Format in editable Word or printable PDF. Customize it effortlessly with our AI tools or seek legal help for personalized tweaks. Free download option available for basic version—upgrade for premium features like unlimited edits and lawyer-reviewed samples.

Important Note: While this ready-to-use format is designed to meet standard Indian legal requirements, it's recommended to consult a local advocate or drug licensing expert for case-specific advice. Not a substitute for professional legal counsel. Explore related templates like Drug License Application Format, Pharmacy Ownership Transfer Affidavit, or Section 65B Affidavit for comprehensive compliance.

(Word count: 528)

AFFIDAVIT FOR SELF DECLARATION BY OWNER AS A PHARMACEUTICAL DEALER

Non-Judicial

BEFORE THE NOTARY PUBLIC AT………………(Name of place)

A F F I D A V I T

I/We, ___________________, W/D/Son of __________________, and _____________________, W/D/Son of __________________, both residing at ___________________________________ (Address with pin code, P.O, P.S, District and State) ,do solemnly affirm and declare:-

1. That, we are the legal partner of firm ___________________________________(Name of firm with address.

2. That, the firm is existing physically on the ground at the address given above at Para 1.

Contd …..P/2

Page-2

3. That, in case any drug/ medical store item supplied by me becomes toxic/not fit for use within its shelf life, the same will be replaced immediately by me-free of cost.

4. That, I/our firm is the authorized dealer for the pharmaceutical companies, for which I have enclosed the photocopies of the dealership certificates, to supply their products of products of any other company at competitive institution rates. I/we will supply only drugs of DGQA registered firms.

5. That, I/we am/are registered dealers for supply of medicines/medical store at the civil/military hospitals for which I have enclosed the photocopies of the empanelled dealership certificate.

6. That, I/we, am/are not black listed/banned by any of the hospital where I/we am/are empanelled as dealer.

7. That, I/my firm is not involved in any impropriety, CBI/police enquiry under the India Drugs Act/NDPS Act.

8. That, I/my firm will abide by the date mentioned in the supply orders to supply the medicine as per their manufacturers quoted in the quotations supplied and samples submitted after Rate Enquire by __________________________________ . In case of any changes e.g. in specifications i.e. manufacture shelf life or otherwise for whatever reason including non availability, written application for the same will be submitted to Commanding Officer 38 AMSD, C/O 99 APO, Whose decision will be final & binding.

9. That, I/my firm has a drug license bearing no DL_____________ dt _________ and valid till _____________. In case the validity of the license expires during this F Y __________(Financial year). I here given an undertaking to this effect that I will get it renewed at the earliest. (Photocopies of the same and separately for Narcotic drugs is being enclosed for conformation).

List of civil/military hospital where empanelled

1. Commandant Officer, ________, Base Hospital, C/o ________.

2. Commanding Officer, ________ AMSD, C/o ____________.

10. That, I/my firm has a valid GST,TIN registration, bearing No:- _________________ (Photocopies of which is being enclosed for confirmation).

11. That, I/my firm is a regular income tax payer and has/have been allotted with PAN card bearing no. __________________, photocopy of which is being enclosed for confirmation.

12. That, I/am firm is willing to supply the medicines/store lower than the MRP and at institutional rates and will not change higher than rates quoted in any Govt. hospital.

13. That, while abiding all the rules and regulation of your organization that may be framed from time to time, I/my firm will provide prompt and efficient services.

Verification: Verified that the contents of the above said affidavit submitted by me are true and correct to the best of my knowledge and belief and nothing has been concealed therein. If the above given information is found to be false at a later date, I will be liable for legal action and can be black listed for future.

Date : ___________

_____________________________

(Signature of the dealer)

Identified by me

Advocate /_____________(Name of Place)

0 PDF downloads

0 Word downloads

Download PDF₹99 Download Word₹99

Important Guidelines

Guideline for Drafting an Affidavit for Self Declaration by an Owner as a Pharmaceutical Dealer:

Usage: An Affidavit for Self Declaration by an Owner as a Pharmaceutical Dealer is often used in the pharmaceutical industry for various purposes, including licensing, regulatory compliance, and business operations. It allows the owner of a pharmaceutical business to make specific declarations under oath regarding their business activities. Here's a concise guideline:

Header: Start with a title that clearly identifies the document, such as "Affidavit for Self Declaration by Owner as Pharmaceutical Dealer."

Affiant Details: Include the full name, contact information, and any relevant identification of the owner making the declaration.

Business Information: Specify the name, address, and registration details of the pharmaceutical business, including any necessary licenses or permits.

Declaration of Facts: Clearly state the facts or declarations that the owner is making under oath. This may include information about the types of pharmaceutical products dealt with, compliance with pharmaceutical regulations, adherence to ethical standards, or other relevant details.

Purpose of Declaration: Explain the reason for making this declaration, such as applying for or renewing a pharmaceutical license, ensuring compliance with pharmaceutical laws, or addressing regulatory requirements.

Sworn Oath: Include a statement indicating that the affidavit is being made under oath, and all information provided is true and accurate to the best of the affiant's knowledge.

Authorization: If required, include a statement authorizing relevant regulatory authorities to verify the information provided.

Signature and Date: Provide spaces for the owner's signature and the date of the affidavit.

Common Mistakes to Avoid:

Inaccurate Information: Ensure that all details and declarations in the affidavit are accurate and supported by documentation or records. Ambiguity: Use clear and precise language to avoid any ambiguity or misinterpretation in the declarations. Failure to Include Required Information: Review the specific regulatory requirements for pharmaceutical dealers in your jurisdiction to include all necessary information. Lack of Witness or Notarization: Depending on local regulations, consider having the affidavit witnessed or notarized for added legal validity. Failure to Notify Relevant Authorities: Ensure that the affidavit is submitted to the appropriate regulatory authorities or licensing bodies as required. Drafting an Affidavit for Self Declaration by a Pharmaceutical Dealer is essential for demonstrating compliance with pharmaceutical regulations and maintaining the integrity of pharmaceutical businesses. Consult with legal advisors or professionals familiar with pharmaceutical laws and regulations to ensure accuracy and compliance with relevant standards.

Frequently asked questions

What is the purpose of the Affidavit for Self Declaration by Owner as a Pharmaceutical Dealer?→

This legal affidavit enables the owner of a pharmaceutical dealership to self-declare their business status, ownership details, and compliance, essential for obtaining drug licenses under India's Drugs and Cosmetics Act, 1940.

Is this affidavit legally valid in India?→

Yes, it is legally valid across India when drafted on appropriate non-judicial stamp paper, duly notarized or attested, and executed as per state-specific affidavit rules.

Do I need to pay stamp duty for this affidavit in India?→

Yes, affidavits require stamp duty on non-judicial stamp paper (typically Rs. 10-100, varying by state); verify with your local Sub-Registrar for exact requirements in India.

In what format can I download this Affidavit for Self Declaration?→

Download it in editable Word (.docx) or print-ready PDF format for easy customization and use in legal proceedings in India.

Can I customize or edit this pharmaceutical dealer affidavit template?→

Yes, this customizable agreement template allows editing of personal details, declarations, and specifics to fit your pharmaceutical dealership needs in India.

Who should use the Affidavit for Self Declaration by Owner as a Pharmaceutical Dealer?→

Pharmaceutical dealers, proprietors, or owners applying for drug licenses, registrations, or certifications from state drug control authorities in India.