Client Application Form
w.e.f. 18/11/2017
Client Name
*
Enter the name of the Lab / Clinic / Hospital / Sample Giving Client
In-charge Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PAN Card
*
Browse Files
Upload the PAN Card of Lab or Hospital or OLC
Cancel
of
Aadhar Card
Browse Files
Upload the Aadhar Card of Owner or Incharge
Cancel
of
Visiting Card
*
Browse Files
Upload the Visiting Card of Owner or Incharge
Cancel
of
Qualification
*
Enter the highest qualification
Email Id
*
Enter primary email id, eg. example@example.com
Alternate Email Id
Enter alternate email id, eg. example@example.com
Mobile No.
*
Enter primary mobile Number
Mobile No. 2
Enter alternate mobile Number
Processing Lab
CPL
BANL
BHOL
CBEL
DELL
HYDL
KOLL
MUML
PATL
CHEL
Select (CPL or nearest RPL)
Distance from Lab
Enter distance in Kms.
Channel
*
SOLC
MOLC
BOLC
FOLC
TOLC
EOLC
TPC
HUB Code
*
Introduced By
*
Enter your name
E Code
*
Enter your E Code
Submit
Should be Empty: