Dealer / Distributor Enquiry Form

Company Information

Company Name *

1. Applicant Details

Full Name *

Firm / Shop Name *

Proprietor / Partner Name

2. Contact Information

Mobile Number *

Alternate Mobile

Email ID *

3. Business Address

Address *

City *

District *

State *

PIN Code *

4. Business Information

Nature of Business

Medical StoreDistributor / WholesalerAyurvedic StoreOther

If Other, Please Specify

Years in Business

Do you currently deal in Herbal / Ayurvedic Products?

YesNo

If Yes, Please Mention Brands

5. Market Coverage

Area / Territory Covered

Number of Retailers Connected

6. GST & License Details

GST Number

Drug License Number (If Applicable)

7. Storage & Distribution

Warehouse / Storage Facility Available?

YesNo

Delivery Vehicle Available?

YesNo

8. Interested Product Category

Ayurvedic CapsulesHerbal SyrupsHerbal OilsHealth SupplementsAll Products

9. Additional Information

Declaration

I confirm that the above information provided by me is true and correct.

Applicant Name *

Date