"申请表封面"
"附表二"
" 四川省绵阳市开办药品零售(连锁)企业 验收申请表"
,"企业名称:"
,"隶属部门(签章):"
,"企业法定代表人:"
,"企业负责人:"
,"同意筹建零售连锁企业,药品零售企业通知书编号:绵食药监许筹字〔 〕第 号"
,"受理通知书编号:"
,"联系人:",,,,"联系电话:"
,"通讯地址:",,,,,,,,,"邮编:"
"申请日期: 年 月 日"
"四川省绵阳食品药品监督管理局制"
"填表说明"
"药品经营企业验收申请表填表说明"
" 一,本表"封面"和"拟办企业基本情况表","应提交及已提交资料表","人员基本情况表"由申请人填写,受理编号由受理人填写. 二,隶属部门,指企业直接隶属的部门或单位. 三,非企业法人单位填写负责人,有隶属部门的还应填写所隶属部门的法定代表人. 四,注册地址,指药品经营活动场所;仓库地址,指药品储存场所. 五,经营方式 :指零售或零售连锁. 六,经营类别:请在处方药或甲类非处方药,乙类非处方药栏内填写"是"或"否"字样. 七,经营范围指:中药材,中药饮片,中成药,化学药制剂,抗生素制剂,生化药品,生物制品(不含预防性生物制品),请根据需要填写. 八,本表以及其它申报资料统一使用A4纸,电脑打印或用蓝黑墨水填写均可,填写应准确,真实,完整,不得涂改和空格.若无栏目所设项目时,注明"无此项". 九,本表所列栏目内容填写应准确,真实,完整,不得涂改和空格.若无栏目所设项目时,注明"无此项". 十,申请人对表中所填内容的真实性承担法律责任."
"企业基本情况"
"企业基本情况表"
"企业名称"
"注册地址",,,,,"连锁类型 (加盟,直营)",,,,"属地 状态 (城市, 乡镇)"
"隶属部门",,,,,,,,,"仓库 地址"
"经济性质",,,,,"经营 方式",,,,"联系 电话"
"法定代表人",,,,,"职称",,,,"药品经 营年限"
"企业负责人",,,,,"职称",,,,"药品经 营年限"
"企业 质量负责人",,,,,"职称",,,,"药品经 营年限"
"门店 质量负责人",,,,,"职称",,,,"药品经 营年限"
"驻店药师",,,,,"职称",,,,"药品经 营年限"
"经营类别",,,"处方药",,"甲类非 处方药",,,,"乙类非 处方药"
" 经 营 范 围"
"从业 人员数","总人数","其 中 药 学 技 术 人 员"
,,"执业药师",,"主任 药师","副主 任药师","主管 药师","药师",,"药士",,"其它"
"营业 场所 情况","营业场所面积(m2)"
,"建筑面积",,"营业面积",,"其它面积","营业用主要设施设备"
"仓储 情况","仓库总 面积 (m2)",,"其中",,,,"仓储主要设施设备"
,,,"常温库","阴凉库",,"冷库"
"验收养护室面积及主要设施设备 "
"人员基本情况"
"企业人员情况明细表"
"岗位职务","姓名","性别","年龄","身份证号","学历","专业","技术职称","执业资格","健康状况","联系电话"
"企业法人"
"企业负责人"

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