Vendor Registration

A: Vendor Capability Proforma

Vendor Name

Registered Office Address

Factory Address

Telephone No

Fax No

Contact Person Name

Designation

Mobile No

Types of Establishment

Constitution of Company

Year of Establishment

PAN No

GST No

Sales Tax Registration No

CIN No

TIN No

FDA License No

Factory Act License/SSI Registration/Shops and Establishment License No

Business Profile

Items Proposed to be Supplied to the Hospital

Name and Address of Bankers & Account No

IFSC Code

MICR No

Credit Limit

B: Commercial Information

Are you in Rate Contract with DGS & D/ Railway/ MCGB/BT/Any other hospital

Principal Customers Name and Address

Product Supplied Value in Rs. Lacs per year

C: Other Information

Please enclose the following documents:

Balance Sheet & P&L Account

Latest Income Tax Details

Copy of Sales Tax License

Copy of FDA License

SSI Registration / MSME Certificate / Shops and Establishment License

GST Registration Certificate

PAN Card Copy

Experience Certificate

NEFT Form

Signature of the Vendor

Date

APPLICATION FORM FOR DEPOSITING PAYMENT AGAINST BILLS IN BANK ACCOUNT BY ELECTRONIC CLEARING SERVICE/NEFT

Name of the Vendor

Vendor Address & Other particulars

PAN NO

GST NO

Mobile No

E-mail Id

Bank A/C Holder’s Name

Bank Account No

Bank Name, Branch & Address

9-Digit MICR Code of the Bank

Account Type (SB / CURRENT)

IFSC Code (Attach xerox copy of cheque)

I hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for reasons of incomplete information, I would not hold the user institution responsible. I agree to discharge the responsibilities as a participant under the scheme.

Signature of the Vendor with seal

Signature of the authorized official from the bank

Bank’s stamp

Date

Vendor Registration

A: Vendor Capability Proforma

B: Commercial Information

C: Other Information

APPLICATION FORM FOR DEPOSITING PAYMENT AGAINST BILLS IN BANK ACCOUNT BY ELECTRONIC CLEARING SERVICE/NEFT

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Our Existing Projects (Balasaheb Deoras polyclinic)

10+

1,85,000+

8+

Polyclinic Project

Key Achievements

Services Offered

About Our Polyclinic