Annexure 1

Depot Delivered Samples – Request Form

SAMPLE REQUEST FORM FOR DOCTORS REQUIREMENT (DDS)

Without MSL code of the doctor, your request cannot be approved.

Employee No.: Name of Employee:

Designation: Request Date:14/07/20
HQ: Task Force: Respiratory
MSL Code (New): Spcl/Ctg:team 2

Doctor’s Name :
Address1 :
Address2 :
Address3 : Sikandra Agra
Pin code : 282007
Tel No :
Mob :

Requirement:
Sr.No. Product Quantity Period
1 Duolin Rotacap 60 rotacap Monthly

2 Foracort 200 rotacap 60 rotacaps Monthly

3 Rotahaler 1 pcs Sos

Note: This sample request should be raised only for qualified prescribers to gain experience on
the product. All the fields mentioned in the above format are compulsory.