Stockiest / Customer Form for PHARMANET CODE

Sr.No. Description
To be Filled By Stockiest / Customer
1 Customer Name / Stockist Name TEAM SURGICAL CO.
Customer Type / Stockist Type (Stockist /
Super Stockist / Hospital / Inst. / Nursing STOCKIST
2 Home) **
3 Owner Name Mr. Anshul Jain
4 Contact Person Mr. Anshul Jain
5 Office Address 43/19-B, East Azad Nagar, Delhi - 110051
6 Godown Address Same as Above
7 City Name Delhi
8 State Name Delhi
9 Pincode No. 110051
10 Place / HQ Delhi
11 Drug Lic. No. -1 2(2896)
12 Drug Lic. No. -2 2(2896)
13 Phone No. Office 22099483
14 Fax Phone No.
15 Mobile No. 9811731304, 9868531304
16 E-mail Ide teamsurgical2005@yahoo.co.in
17 LST No. No : 07490258756
18 CST No. No : 07490258756
19 VAT Reg. No. No : 07490258756
20 PAN No.
21 Service Tax No.
22 Bank Name ICICI Bank Ltd.
23 Bank Account No. A/C No : 102405000155
24 Local / Outside (HQ) Local
25 Division Group Critical Care Division
26 Delivary Mode
Constitution (Partnership / Properiter /
Properiter
27 Pvt. Ltd./ Public Ltd.)
To be Filled By TSE/TSM/RSM
Division Code ( Genric / Medical Device/
Critical Care Division
1 Crital Care/ Ear & Eye/ Perantel)
Customer Class ( Normal Stockiest /
Super Stockiest / Dis. On Excise/ Instution/ Normal Stockiest
2 Hospital)
Customer Tax Class (Like Taxable / Inst.
Taxable / Against D Form/ Exmpeted / Like Taxable
3 Against Form)
4 Payment Terms Advance Cheque

1 Customer / Stockiest HQ (Teritory) East Delhi

2 Stockiest attached with CA Saluja Medicose
3 Stockiest attached with Region Delhi
4 Stockiest attached with Zone Delhi
5 Stockiest attached with TSE
6 Stockiest attached with TSM Jatin Dhawan
7 Stockiest attached with RSM Satendra Pal Singh
8 Stockiest attached with ZSM
9 Date of Association with Nirma Aug-10

1 Customer Code / Stockist code

Signature of Stockiest & Date

Jatin Dhawan (20-08-2010)

Signature of TSE/TSM & Date

Signature of RSM/ZSM/Mktg HO & Date

Signature of Master Team at HO