Business Partner Application Form

Any others,
Structure of your company Partnership Proprietorship please specify

Registered Address with PINCODE

Name of Owner/Directors/Partners

Contact details (email and telephone no.

of atleast 2 of the above important persons)
Trading Manufacturing Service
Core Business of your organisation

Geograpahical Area which you are actively covering

(Please mention States or Districts)

Do you have branch offices, if yes, please mention the locations

Experience in the field iof Healthcare (no of years)

Laboratory products
Whether you have valid applicable licenses for dealing with ? X-ray machines Ultrasound machines and reagents

Any others,
Whether you have required tax registeration GST PAN please specify

2014-15 2015-16 2016-17
Financial Turn Over for the last 3 financial years (in Rs.)

Sales Service Admin

No of employees working in your organisation

Names Since when

Names of the Companies you represent in the field

of Healthcare Imaging and since when ?

Names Since when

Names of the Companies you represent in the field

of Laboratory Diagnostics and since when ?

Names Since when

Any other prominent companies that you represent in

the field of Healthcare and since when ?

Customer 1 Customer 2 Customer 3

Names of 3 Important Customers that you handle,

who can be your strong supporters

Name of the Award Year

Please give the details of the Awards that you have won

Any Other Information that you want to give

about your organisation

Unrestricted