DEALER INQUIRY FORM

DEALER INQUIRY FORM

Details of Applicant for Dealership (Basic Information)
Company Name
Your Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Details
Name of Contact Person

First NameLast Name
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
E-mail ID Official *
Other Email
example@example.com
Website URL
Business Details
Type of Business Entity
Other (please specify)
Year wise turn over
2018-19
2019-20
Year of Starting Business
Number of Sales Executives
Number of Service Executives
Area of Coverage
States
Districts
Details of Office Space
Details of Showroom Space
Segments Covered

GovernmentPrivateProjectsTenders (Indian)Turnkey ProjectsConsultancy
Details of Businesses
Types of Products Dealt with
Principal Companies
Are you dealing with OT Lights?

YesNo
If yes, please specify brands and give details
Are you dealing with Modular Operation Theatres?

YesNo
If yes, please give details
Are you dealing with Disinfecting Equipment?

YesNo
If yes, please give details
Are you a manufacturer?

YesNo
Do you have any other sister concerns?

YesNo
If yes, please give details
I/we certify that the information given in the application form is correct.
Designation
Date

MonthDayYear
Date
Place
Remarks
Should be Empty:

Contact Details