3SCARE PHARMACEUTICAL
📍 Prithvi Homes, Jeedimetla, Hyderabad - 500055
1
Party & Legal Details
2
Business Profile
3
Declaration & Signature

Step 1: Party & Legal Details

Please enter party name

2. Mailing Address

Please enter mailing address
Please enter valid 6-digit pincode

3. Contact Details

Please enter office phone
Please enter valid 10-digit mobile number
Please enter valid email address

4. Residence Address

5. LST / Trade License

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6. Drug License

Please enter 20B License No.
Please enter 21B License No.
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7. GSTIN

Please enter valid 15-character GSTIN
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8. Banker's Details

Please enter bank name
Please enter branch name
Please enter city
Please enter account number
Please enter IFSC code

9. Constitution*

Please select constitution

10. GSTIN Registration Date

Please select registration date

Step 2: Business Profile

11. Preferred Transporter

12. Experience in Pharma Trade

Please enter years of experience

13. Annual Turnover

Please enter annual turnover
Please select financial year

14. Companies Currently Distributing

Company Name Category Since (Year) Action

15. Area / Territory Covered

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16. Retail Chemists Covered

Please enter number of retail chemists

17. Field Force

Please enter number of salesmen

18. Infrastructure

No
No
No

19. Weekly Closing Day*

Please select weekly closing day

20. Type of Business

21. Transport Priority

Step 3: Declaration & Signature

Declaration

I/We hereby declare that the above information furnished is true and correct to the best of my/our knowledge. I/We agree to abide by all terms and conditions of 3Scare Pharmaceutical and understand that false information may lead to cancellation of appointment.

Please agree to the declaration

DISTRIBUTOR SIGNATURE BLOCK

Please enter signatory name
Please enter designation
Please enter place
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📋 FOR OFFICE USE ONLY ▼

FOR 3SCARE PHARMACEUTICAL

Company Stamp Area
✅

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