Schedule-2
(Relating to Rule 14)

Form for sending the sample of the drug
Ref No.
To…………….
The sample of the drug kept in the sealed box is, hereby, sent mentioning the following details for examination and analysis as per the Drugs Act, 2035(1978) and the Drugs Inspection and Investigation Rules, 2040(1983). I do, hereby, request to send a report to…………….of the outcomes of the examination and analysis of the drug and the condition of the box while received.
1. Number of the sealed box
2. Name of the drug and quantity
3. Serial number of the sample of the drug mentioned in the record
4. Indicative number mentioned outside the pack
5. Sample of seal set outside the box and the pack.
6. Date and place of collection of the sample of the drug
7. Matters to be examined and analyzed
8. Other necessary matters, if any:
Name of the Office: Inspector’s
Stamp of the Office Signature
Date: Name and surname