Registration Form
(*) Required field
Name of Farm:
*
Name Of Propreitor/ Partners / Director:
*
Address of Farm:
*
Constituency:
*
Police Station:
*
Post Office:
*
Village / Ward:
*
District:
*
Pincode:
*
Mobile No.:
*
Alternate Mobile No.:
e-mail:
Nature of Business:
*
Wholesale
Retail
Drug License No. :
*
Competant Person (W/R):
License No. of the Pharmacist:
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