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1. Basic Company Details

Supplier / Firm Name *

Business Type *

Registered Address *

Office / Correspondence Address

Same as Registered Address

City *

State *

Pincode *

Contact Person Name *

Designation *

Mobile Number *

WhatsApp Number

Email ID *

Website

2. Registration & Legal Information

PAN Number *

GST Number *

CIN / LLP Number

UDYAM / MSME Registration No.

FSSAI License Number

Drug License Number (Form 20B / 21B)

Drug License Validity (Start Date)

Drug License Validity (Expiry Date)

Wholesale / Retail License

Import License Number (if any)

3. Banking & Payment Details

Bank Name *

Branch Name *

Account Holder Name *

Account Number *

IFSC Code *

Payment Terms *

Billing Name & Address (for invoice) *

4. Compliance & Documentation (Attach Copies)

Cancelled Cheque *

PAN Copy *

GST Certificate *

Drug License Copy

FSSAI License Copy

Authorization Letter (if applicable)

Company Profile / Product List

Transport Details (if applicable)

5. Business & Operational Information

Brands / Companies Represented

Average Monthly Supply Capacity

Key Products Supplied

Primary Market / Region

Existing Customers / Distributors

Contact for Dispatch

Contact for Accounts

Contact for Sales

Preferred Communication Mode

6. Declarations & Additional Information

Declaration

We hereby declare that all information provided above is true and correct to the best of our knowledge.

Authorized Person Name *

Designation *

Date *

Company Seal / Stamp

To be affixed on printed copy

Optional (Recommended for Pharma)

Cold Chain Handling Capability

GST Return Filing Frequency

Credit Note & Return Policy Acceptance

Quality & Expiry Commitment Clause

Primary Warehouse Address (for pickups/returns)

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