FORM IV (To be submitted In seven copies) (See paragraphs 2, 8, 9 and 10) Form of Application for approval or revision of price of Scheduled formulations imported in finished form. 1. Name of the company. 2. Address of the Registered/ Head Office/ Factory, if any. 3. Reference to Permission, if any, given by Drug Control Authorities for import/ sale of the item. 4. Name of the imported formulation/ therapeutic group. 5. Type of formulation (capsule/ tablet/ inj. etc.). 6. Composition of the formulation. 7. Type of Packs (strip/ vial/ ampoule etc.). 8. Pack size (10's etc/ 10 ml etc/ 5 gms etc.). 9. Country from which imported and date of import. 10. (Quantity/ Number of packs imported with Batch/ Lot Number.)

• Definitions • Fixation of Sale Prices    of Bulk Drugs • Bulk Drug Manufacturers • Calculation of Retail Price • Power to fix Formulation Prices • Power to Fix Ceiling Price • Power to recover Dues • Power to recover Overcharged Amt. • Issue of Price List • Power to Review • List of Price Controlled Drugs • Application for Bulk    Drug prices : Form I • Information for non-Scheduled    Bulk Drugs : Form II • Application for Formulation    Prices : Form III • Form IV, V, VI • The Third Schedule

11. C.I.F. Value in Foreign Currency. (Not to include bank commission, interest etc.) Total (Rs.)     Per Pack (Rs.) 12. C.I.F Value in Rs. actually paid. (Not to include bank commission, interest etc.) 13. Duty of customs, if any, actually paid. 14. Clearing Charges (with details) actually incurred. 15. Landed cost (12+13+14). 16. Packing Materials, if any, as per norms. (Applicable in case of repacking) 17. Packing Charges, if any, as per norms. 18. Landed Cost (including repacking cost, if any). (15+16+17) 19. Margin @ 50%. 20. Duty of Excise, if any. 21. Retail price claimed (18+19+20). 22. Existing retail price, if any : (copy of approval letter to be enclosed) NOTES:- Information furnished should be certified by the Authorised Signatory of the company and a Cost/ Chartered Accountant. In respect of SI. Nos. 11 to 14 and 16, the claims shall be supported by certified copies of documentary evidence. The Information furnished above is correct and true to the best of my knowledge and belief. Authorised Signatory: Place : Name: Designation: