Stockist Appointment Form for 2019-20

Stockist Firm Name

Stockist Code

If Yes, kindly mention name of the alternate firm/s

Any other firm/s operating in
same business

Year of Business
Establishment

Name of the Proprietor

Name of Purchase
Manager/Operations Head

Registered Address
Address:
District:
State:
Pin Code:

Contact Details of Key

Person/s Mobile - Landline

Email Id -

Infrastructure (non mandatory) & Manpower

Total Shop Area (in sq.ft)

Total Warehouse Area (in sq.

ft)

Internet Connection, IT
Hardware Internet Connection – Yes/No (Please tick)
IT System – Yes/No (Please tick)

Manpower Details
Sales Staff count –
Admin & other staff count –
 Stockist Appointment Form for 2019-20

Business Details
Total Turnover Per month

HORIZON GX Business Per

Month
Top Competitor Details NAME OF THE COMPANY MONTHLY BUSINESS
1.
2.
3.

Other non-pharma business

details Name of the firm -
Sector -

Geographical Coverage & Customers

Districts Covered No. of districts -
Names of Districts -

Customer Coverage
No. of chemists - No.

of semi stockists -

No. of doctors -

Other Details
GST Details

Drug License Number (D/L)

(non mandatory)

Bank Name & Address

Bank Account Details

 Stockist Appointment Form for 2019-20

References (non mandatory)

Sr No. Name Address Telephone Occupation

I/We certify that the information given Name & Signatures of in the application form is correct and
Authorised Signatory with complete

Name & Signatures of Authorised Signatory Approved by

Official Seal
C&F

BM

RSM

ZSM

List of Enclosures

a. GST Certificate
b. Drug License
c. Copy of Shop License
d. Passport size Photographs of Owner/s
e. Advance cheques – 2 (As per bank details mentioned above)