Ayush Quality Mark

1. Name of Manufacturer (Firm) * (Complete name as mentioned in document establishing the entity)

2. Address of Manufacturing Premises (Complete Factory Address with City, Pin Code & Sate/U.T., Country) Address *

City *

Pin Code *

State / U.T.*

Country *

3. Address of Regd. Office/Office (if different from 2 above) (Complete address with City, Pin Code & Sate/U.T., Country) Address *

City *

Pin Code *

State / U.T.*

Country*

4. Other location(s) of the firm where also manufacturing activities are carried out (Separate applications need to be submitted for each such location for recognition)

5. Contact Details of the Firm (Give Telephone No., Mobile Nos., Email Id)

Telephone No.*

Mobile No.*

Email Id *

6. Type of Firm & Legal Identity (Proprietorship, Partnership, Ltd. Pvt. Ltd., LLP, Govt., PSU etc.)*

7. Scale of Firm Large Scale/MSME * b) In case of MSME, mention Udhyam/ other relevant Registration Nos. & Date

8. Licence to manufacture Ayush Products * (Mention name of the authority and Licence No. & Date)

9. Management of Firm (Name & Designation of Top Management & Key Functionaries)*

10. Whether firm has in-house laboratory for testing and assuring quality (Yes/No)*

11. Quality Control Personnel (Mention Names & Designations of Head of QA/QC)

12. Ayush Products manufactured*

13. Ayush Products for which recognition is sought

14. Credentials in support of seeking recognition for products at 13. above

a) Registration with a foreign regulator*

Minimum Pdf Size to 2 MB

b) WHO GMP/CoPP based on WHO GMO issued by CDSCO – No. & Date of Issue with list of products*

Minimum Pdf Size to 2 MB

c) Ayush Premium Mark under VCS by QCI – Name of Certifying Body*

Minimum Pdf Size to 2 MB

15. Adverse reporting/action by the regulatory/ certifying body, if any

16. Name and Address of Consultancy Firm/ Consultant engaged, if any for Any Ayush related activities.

17. Payment of Application Fees (Mode, Txn Id, Payment Date, Cheque No, Bank etc.)

Account Name:	Ayush Export Promotion Council	Bank Name:	Axis Bank
Account Number:	926010005729791	IFSC Code:	UTIB0003108
Branch:	South Extension II, New Delhi, 110049	Account Type:	Current

Amount *

Mode of Payment *

Txn Id / Cheque / UTR no Ref.no. *

Payment Date *

Remarks

Bank*

18. Any other Information

19. Declaration –

It is hereby declared that the information, as provided above are true and the documents attached in support of the application pertain to us and are authentic. I undertake to inform the (PO), in case there is status change in respect of any information or the attached document.

Authorized Name*

Designation*

Date*

* Application to be signed by Proprietor, Partner, Managing Director, Director, CEO etc. or in his absence, by his authorized representative.

Ayush Quality Mark – Product Manufacturers

ANNEX 1 – Application Form for Ayush Product Manufacturers