VENDOR REGISTRATION REQUEST FORM

REGISTRATION/RENEWAL (2016-2018)
(BOTH HARD COPY AND EMAIL/SOFT COPY ARE REUESTED TO BE SUBMITTED)
LAST DATE FOR SUBMISSION: 31 AUG 2016

Ser No Documents required to be submitted To be filled by For Office use

Applicant only (Yes/No)
(Manufacturer/Dealer/Vendor) (Assign page
No serially to
following
documents)
1. Application on company letter head to be addressed to the
Commandant, AFMSD Delhi Cantt-10
2. PAN No of Firm (Proprietorship Firms – Indl PAN)
3. TIN No of Firm
4. Drug License valid from the current financial year till
September 2018 ( Proprietor name to match with Licensee)
5. For Manufacturers turn over statement of last 3 years > 20
crores for every year (duly audited by a CA)
6. For Dealers and Distributors turn over statement of last 3 years
in actual (duly audited by a CA)
7.* Registration documents if already registered with any
state/central govt agency if available
8.* Supply order of any state/central govt agency if available
9. Copy of DGQA registration/GMP Certificate/original inventor of
molecule
10. 03 years manufacturing and marketing certificate issued
recently (not earlier than one year from date of registration by
state drug controller) where applicable
11. Electronic clearance scheme (ECS) mandate form
12. In case of distributor/dealer copy of original letter head which
quotations would be submitted along with authorized
signature and one recent photograph of the owner in front of
the office premise. (Not required for Manufacturers)
13. Telephone Number/FAX Number
14. Email ID
15. Dispatch of scan copies of all documents through registered
Email at Ser No 14
16. Hard copy of all documents submitted
17. Category in which the registration is sought & valid
license/distributorship is held

(a) Human Medicines and Veterinary Drugs Yes/No

(b) Surgical Consumables Yes/No
(c) Ophthalmology Stores Yes/No
(d) Dental Stores (Proper category Yes/No
(e) Aseptic Furniture to be maintained Yes/No
(f) Orthopaedic Implant/Stores in bold capital on Yes/No
(g) Laboratory Kits this form) Yes/No
(h) Radiology Films/Consumables Yes/No
(j) Non Expendable Med Stores Yes/No
(k) Other Items Yes/No
18. e-procurement login ID (a)
(b)
(c)
(d)

Signature of the proprietor/authorized signatory for the applicant

Name, ID Proof details, PAN/AADHAR/DRIVING LICENSE of the applicant

Tele No: _____________________________
Email ID ______________________________
I fully understand my registration with AFMSD Delhi Cantt in the Vendor Database is subjected to submission of
all the above mentioned documents. I have not been able to produce the following documents as mentioned
below which I undertake to submit at the earliest.

(Sign of Vendor)

(Name of the vendor)

Date: (Name of firm)

FOR OFFICIAL USE

OIC Registration Cell ______________________________

OIC Independent Member __________________________

OIC PCMC Cell ___________________________________

Documents submitted for registration/renewal have to be serially assigned page nos and this must be entered in
the column on last page

(This check list will be attached on top of all documents)

All documents are mandatory for submission except those documents serial no marked asterisk (*).
*Ser No 9 & 10 is not required in case of dealer/distributor.
All firms even if applying for renewal, are requested to submit all requisite documents.
Email ID of AFMSD Delhi Cantt – atmsddc@nic.in
Photocopy of this request form won’t be accepted.