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 Level State Level Local (For you locality)
Do you have any experience in Distribution?  Yes No
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.