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Dealer Enquiry Form

 
Name of the Firm :
Year of Establishment :
Type of the Establishment :  Proprietorship   Partnership 
 Private Limited  Limited 
Name of the Directors/Partners :
Contact Name :
Address 1 :
Address 2 :
Area :
City / Town :
State :
Telephone :
Mobile :
Fax :
Email :
Years of Experience in Business :
Current Nature of Business :
No. of Sales Staffs :
No. of Service Staffs :
No. of Administration Staffs :
Show Room (If any) :  Yes  No 
Last Three Year's Turnovers :
Product of interest :  General X-Ray   Mobile X-Ray 
 Digital Radiography   Digital R & F System 
 Cardiac System   Tube Support 
Area of Operation :
Investment Capacity (in Lacs) :
Banker's Name :
PAN No. :
TIN No. :
CST No. :
Service Tax No. :
Area of Office
(Not less than 500 Sq.Ft)		 :
Reference 1 (Name) :
Address 1 :
Address 2 :
Area :
City / Town :
State :
Reference 2 (Name) :
Address 1 :
Address 2 :
Area :
City / Town :
State :