Name of the Party: *

Nature of Business :
CompanyPartnershipProprietorship
Mobile No. : *
Address of Business (Pin Code is Must) :
Name of the software (for Billing) :
Contact No. (Phone / Mobile) :

Email ID : *

GST No. (Kindly attach certificate copy)
DL No 20B & 21B (Kindly attach certificate
copy)

Year of Establishment :

Coverage area :
Capital employed (In Lacs) :

Annual turnover (In Lacs) :

Bank Name & branch Address :

A/c No. :
IFS code :

Name of the companies being services as
Stockiest / Distributor (for OTC mention the
Brands also)

No. of Field Personnel employed :
Total no. of parties / retailers serviced by the
firm :
Distribution facilities :

Distributors / Stockiest Margin
Terms and conditions :

I/WE AGREE TO THE ABOVE & PROMISE TO COMPLY WITH ALL THE ABOVE MENTIONED TERMS.

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