APPLICATION FORM TO BECOME DISTRIBUTOR OF ELIXIR LIFESCIENCES

    Name of the Applicant

    Name of the Company/ Firm

    Address

    Email

    Phone No.

    Level at which you can become a Distributor

    District LevelState LevelLocal (For you locality)

    Do you have any experience in Distribution?

    YesNo

    Brief History of the Distribution of the Products you have done so far/ Details of your present Business.

    Name of the company for whom you have done distribution

    Name of Company

    Year

    To

    Last One year Turnover (INR)

    Investment Capacity (INR)

    NOTE:
    1. The information given in this form would not be used anywhere and would be highly confidential.