Name of the Firm*:

Type of the firm*:

Sale Tax No:

Drug Licence No:

Mailing Address:

State*:

Land Line No.:

Mobile No*:

Email ID:

Current area of working:
(Please specify the name of Districts)

Proposed Area of Working:
(Name of the districts shall be targeted for Axis)

Name of the companies with whom current business exist:

Current Turnover / Month in Rs.:

Proposed Turnover with Axis Life science:

Major compositions marketed in your area:

Your Specific business Requirement (If any):