Specialized retail pharmacy application unit: application date: Labor and Social Security Bureau printed pharmacy name business license registration number legal representative ownership form business area unit address zip code contact person contact phone number drug license number unit account bank and account number personnel composition pharmacy technical personnel total number of titles classification senior title, intermediate title or junior title business personnel other personnel Total Signature of the legal representative of the content of the application: (application unit seal) on the day of the labor security department review opinion (seal) on the day of the month Description: First, fill in with a pen, the requirements of the handwriting neat and clear, the content of the real. Second, the "application content" column by the retail pharmacy to fill in the intention to apply for the qualification of fixed-point. Third, the last column by the administrative department is responsible for filling out. Fourth, the retail pharmacy to submit this application, to be attached to the following materials: 1, a copy of the drug business license, certificate of conformity and business license; pharmacist or above, the title of the technical staff to prove the material; list of drug products and the previous year's business income and expenditure; drug supervision and management, price supervision and inspection of the Department of proof of conformity; 5, other prescribed materials. Labor security department review opinion (seal) Year Month Description: I. Fill in with a pen, require handwriting neat and clear, the content is true. Second, the "application content" column by the retail pharmacy to fill in the intention to apply for the qualification of fixed-point. Third, the last column by the administrative department is responsible for filling out. Fourth, the retail pharmacy to submit this application, to be attached to the following materials: 1, a copy of the drug business license, certificate of conformity and business license; pharmacist or above, the title of the technical staff to prove the material; list of drug products and the previous year's business income and expenditure; supervision and management of pharmaceutical products, the price department supervision and inspection of the certificates of conformity; 5, the other prescribed materials.
Please adopt