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Application Form For Import of Life Saving Drugs, Medicines, Equipments Under Notification No. 50/2017-Customs, Dated 30.06.2017

The document is an application form for importing life-saving drugs, medicines, and equipment under Notification No. 50/2017-Customs. It requests information such as the patient's name, age, address, disease, treating hospital. It also requires a list of life-saving items to import, prescriptions, certificates from treating physicians that the items are life-saving and unavailable in India, utilization certificates, and copies of treatment records and identification documents. The treating physician must also certify that the listed items are essential to save the patient's life and are not manufactured in India.

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88 views

Application Form For Import of Life Saving Drugs, Medicines, Equipments Under Notification No. 50/2017-Customs, Dated 30.06.2017

The document is an application form for importing life-saving drugs, medicines, and equipment under Notification No. 50/2017-Customs. It requests information such as the patient's name, age, address, disease, treating hospital. It also requires a list of life-saving items to import, prescriptions, certificates from treating physicians that the items are life-saving and unavailable in India, utilization certificates, and copies of treatment records and identification documents. The treating physician must also certify that the listed items are essential to save the patient's life and are not manufactured in India.

Uploaded by

chandanshallu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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APPLICATION FORM FOR IMPORT OF LIFE SAVING DRUGS, MEDICINES,

EQUIPMENTS UNDER NOTIFICATION NO. 50/2017-CUSTOMS, DATED 30.06.2017

1. Name of the Patient:-


2. Age:-
3. Address:-
4. Name of Disease:-
5. Name of the hospital where treatment is being received:-
6. List of Life Saving drugs/equipments under notification No. 50/2017-Customs(Deptt. of
Revenue):

S. Name of Drug Strength Quantity which may Period upto which


N. be imported the quantity
mentioned

7. Whether prescription and certificate from authorized


Treating specialist attached or not? Yes/No
8. Certificate from the treating Physician that drug is
a) Life saving for the patient (attached). Yes/No
b) Not manufactured and not marketed in India. Yes/No
9. Utilization certificate stating inter-alia that the
Medicine/Drug for which letter was issued earlier,
was utilized by the patient concerned. (This certificate
may be given by the treating physician) Yes/No
10. Certificate –Form 12B attached or not? Yes/No
11. Copy of record of treatment taken for the last 3 months. Yes/No
12. Copy of patient Aadhar Card attached or not? Yes/No
13. Copy of Applicant Aadhar Card attached or not? Yes/No
(Note: All the documents are mandatory. Please do not leave any column blank/Unanswered)

Place- Applicant Name-


Date- Signature -
CERTIFICATE FROM THE TREATING SPECIALIST
(In reference to the Notification No. 50/2017-Customs, Dated 30.06.2017)

I, Dr. working as in

the Hospital hereby certified that


Shri./Smt./Mis./Master , Age
S/O,W/O, D/O,H/O is suffering from
(Diagnosis of Diseases) For the

last Days Months Years.

This is a life threatening disease. For his/her treatment, the following


Medicine/drugs/equipments are required in the quantity and strength (in the case of
drugs) given below:

S. Name of Drug Strength Quantity which may Period upto


N. be imported which the
quantity
mentioned

I hereby certify that above mentioned drugs/medicines/equipments are life-


saving to the patients and are not manufactured and marked in India. I recommend that
the above drugs/medicines/equipments should be imported for saving the life of the part.

Name of the Doctor-

Designation-

Name of the Hospital-

Delhi Medical Council Registration No.-

Signature of the Doctor with Date-


UTILISATION CERTIFICATE

It is certified that Shri./Smt./Kum………………………………………………… is


suffering from………..………………………………………..(Name of Disease) has
been prescribed the following costly medicines for the recovery of
his/her Disease.

Name of the Medicine/Drug………………………………………………….. was


prescribed by me on………………………….for the period from
……………..……..to ………………………….. and the quantity supplied for the
period has been completely utilized.

Signature, Seal & Name


of the Treating Specialist.

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