Name of Firm & Address                                      

Telephone No. Off. / Shop                                                    Resi.

Mobile No.of the contact person                                   

Year of establishment of the firm                          

District / Area to be represented                          

TIN No                                                              

Sales Tax No                                                         Dated  

Central Sales Tax No                                              Dated  

Drug License No                                                     Dated  

Names of Partners / Proprietor / Directors

Name & address of Bankers                              

Name of Transport                                            

Approx. Annual Turnover : Rs.                           

Field Staff              Storage Facility            Sq     

Vehicle arrangements                                      

Territory Covered                                             

Approx. expected monthly sales
(nett) in our current product range .          Rs.    

Amount of Security Deposit offered :        Rs.    

Other information                                             

Date