DISTRUBUTOR/STOCKISTSHIP

APPOINTMENT FORM

Date of Proposal :
Firm Name :
Type of Registration : (Proprietorship/Partnership/ Company)
Address/Office/Godown: :

Email/Website :
Telephone No :
Mobile No :
Name & Contact Details of Authorized person :
Date of Incorporation :
GSTIN No: PAN No:
Drug License 20B: 21B:
Food License No:
Proprietor / Partner / Directors residential address, phone nos:
Sl.no Name Phone No Mail ID Address
1
2
3
4
Bank Details:
Account Name: Name of Banker with Address:
Name of Authorized Signatory:
Bank Account No: Bank IFSC&MICR Code:
Annual Turnover in Lakhs:
No of filed force:
Details of other Companies being serviced as Stockist /Distributor (For OTC -mention the Brand also)

Annual Avg Stock Avg Stock

Business Holding in Maintained (in Direct/ No.of Stock statement &
Sl.No Company Name No of years Turnover Lacs Days) Bank Days order submit date
Details of Stockistship discontinued if any, with reasons:
Transporter Preference
1) 3)
2) 4)

MARKET COVERAGE
Existing Stockist details in Same Town/Territory Sale value in town/territory
1
2

Expected increase in Business per month: Expected sales for all div:
Reason for appointment of stockist:
Service effiency:

No of Chemists/Retailers: No of Nursing Homes:

No of Major Institutions: No of Chemists / Retailers Blacklisted:

Areas and districts covered:
Sales:
(1) Trade Details
(a) % of sale to wholesalers (b) % of Retail Sales
(c) % of Institutional Total 100% (a)+(b)+(c )

Any other Information:

I declare that the above is true to the best of my knowledge also agree to abide by your terms and conditions.

(Stockist/Distributor signature with stamp)

Stockiest Assigned To
Headquarter :
Region :
Zone :
Regional head's Comments :

Signature of sales Head)