DISTRIBUTOR FORM

Name of the firm:

Address:

City:

Pin:

District:

State:

Phone No 1:

Phone No 2:

Mobile No 1:

Email Id 1:

Name of the Partner/Directors Residence Address:-

Name:

DOB:

City:

Pin:

District:

State:

Name:

DOB:

City:

Pin:

District:

State:

Name:

DOB:

City:

Pin:

District:

State:

Contact Person Name:

Designation:

Career Summary:

Drug License No 1:

Drug License No 2:

GST:

PAN No:

Bank Name:

Bank Address:

City:

Pin:

District:

State:

Expected Business

First Three Months

After Three Months

After One Year

Working Sytem: SELF YesNo

Medical Sales Represntative:

Your tentative Investments for business:

Dealing of other company if any:

Signature with Firm Stamp: