WWW.NURECA.

COM

Distributor Appointment Form

NAME & ADDRESS:- TELEPHONE NO-

E-MAIL ID-

MOBILE NO-

MOBILE NO-

RESIDENCE ADDRESS

NATURE OF OWNERSHIP

NAME OF PROPRIETOR/PARTNER

Father's Name
DATE OF INCORPORATION

TYPE OF BUSINESS

Area of Godown( Sq. Ft) Address-

Drug Licence No.

GST NO

PAN NO

AADHAR NO
Banker's Name & Address From Bankers(in Lacs)
Cash Credit
Others Total-

Total Annual Turn Over Rs-

In Lac

Capital Employed Rs

Capital Employed Rs

In Lac

Details of Distribution of others Companies- Please give the details.

Regd. Office :128 Gala Number Udyog Bhavan, 1st Floor Sonawala
Lane, Goregaon East Mumbai City MH-400063
Marketing Office : 110, Industrial and Business Park Phase 1, Chandigarh, India - 160002
USA Office : 276 5th Avenue, Suite 704-397 New York 10001 USA
Phone No. +91-172-3078163 Cin : U24304MH2016PTC320868
 WWW.NURECA.COM

Name of Company No. of Yrs Avg. Stocks Payment Policy

Maintained Direct/Bank No. of Days

Expected average sales monthly of Nureca-

1st ORDER DETAILS
PRODUCT:- QUANTITY:-
1.
2.
3.
4.
5.
1 YEAR PROJECTION DETAILS
1.
2.
3.
4.
5.
Proposed Security Rs-
No. of Salesmen:- NO. OF TOTAL STAFF:-
If any delivery vehicles give the details-
Market Coverage-
Total No. of District in State

No. of Districts Covered

Total No. of Stockist Covered-

Any other Information-

I declare that the above information is true the best of my knowledge. We also agree to abide by terms & condition of the
company.

Signature with stamps

Appointed By Field Authorized By Controlling Manager Verified By CFA Approved By Director (Marketing)
Sign Sign Sign & Seal Sign & Seal

Regd. Office :128 Gala Number Udyog Bhavan, 1st Floor Sonawala
Lane, Goregaon East Mumbai City MH-400063
Marketing Office : 110, Industrial and Business Park Phase 1, Chandigarh, India - 160002
USA Office : 276 5th Avenue, Suite 704-397 New York 10001 USA
Phone No. +91-172-3078163 Cin : U24304MH2016PTC320868