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Prospective Client Form (Stockist) For (India)

Stockist

^*All fields must be filled.

Firm Name^* :

Address :

Nearest Land Mark :

PIN :

Area(Sq. Ft) :

Computor :

Man Power :

Internet Connection :

Date of Establishment^* :

(Click to Select Date)

PAN No^* :

Drug Lic. No :

Tin No^*:

Date :

(Click to Select Date)

C.S.T No^* :

Date :

(Click to Select Date)

Phone No^*:

Fax^* :

Mobile No :

E-mail ID^*:

Type of Firm^*:

Name of Owner :

1 :

2 :

3 :

4 :

5 :

Designation :

1 :

2 :

3 :

4 :

5 :

Bankers^* :

CURRENT OPERATION (EXISTING LINES) :

Area Coverage (No. Of Outlets) :

(Please type below words in text box)

Security Code:

Outstanding MSME Award,
2009 Conferred by Federation of
Gujarat Industries ( FGI)