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KHC Healthcare India Pvt Ltd Distributor Assessment Form
  
Please fill the form completely for a quick decision.
Company name:*
Name of contact person:*
Complete office address:*
Mobile:*
Office telephone:*
Email:*
Fax:*
Website (if any):
Type of company:
When founded (Mention Year):*
Years of experience:*
List names of companies you are associated with :*
List names of companies you are associated with on exclusive basis and non exclusive basis. Also mention territory covered :*
Turnover for last 3 years*
        2013 - 2014
        2012 - 2013
        2011 - 2012
Number of sales personnel :*
Number of service personnel :*
Name of your top 5 prime customers :*
Storage facilities/Cold Room/No. of Refrigerators:*
Minimum 2 months stock holding:*
Bank Name:*
Bank Address:*
Drug License Number:*

Date of Issue
Date of Expiry
Central Sales Tax Number:*

Date of Issue
Date of Expiry
Local Sales Tax Number:*

Date of Issue
Date of Expiry
TIN #:*

Date of Issue
Date of Expiry
PAN #:*