Central Bureau of Narcotics
(Psychotropic Substance Control System)
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Application form for Registration of
Wholesalers of Preparation(s)
of Psychotropic Substances
1.
Details of
Wholesaler
* (All Fields Marked * are Mandatory)
(i)
Name of the Company/Firm
*
(ii)
Company/Firm Under Special Economic Zone (SEZ)
*
Yes
No
Note: A company/ firm, which have units within as well as out-side SEZ, will have to obtain two separate Registrations
(iii)
Address of Registered Office
Address Line 1
*
Address Line 2
Address Line 3
Village/Town/City
*
Pin Code
*
State
*
Select State
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chhattisgarh
Dadra and Nagar Haveli
Daman and Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Other
Pondicherry
Punjab
Rajasthan
Sikkim
Tamilnadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
District
*
Select District
(iv)
Address of Corporate Office
Please check incase address is same as that of Registered Office
Address Line 1
*
Address Line 2
Address Line 3
Village/Town/City
*
Pin Code
*
State
*
Select State
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chhattisgarh
Dadra and Nagar Haveli
Daman and Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Other
Pondicherry
Punjab
Rajasthan
Sikkim
Tamilnadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
District
*
Select District
(v)
Contact Details of Authorized Signatory
*
Remove
Name
Designation
Tel No with STD Code
Mobile No with Country Code
Fax No with STD Code
Email
Primary
Message
Designation and Email Required.
Note : The verification mail and all communications will be sent to the Primary Authorized Signatory
(vi)
PAN No. of the company/ Firm
*
(vii)
Website Address
2.
Certification Details
(i)
Company Incorporation Certification Details
(a) Certificate No.
(b) Date of Issue
(c) Issuing Authority
(ii)
Details of IE Code by DGFT
Yes
No
(a) IE Code
(b) Date of Issue
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