Proposed Stockiest Name (To be filled in by ZSM/DSM/RSM Only)(To be Filled in by Depot/C&F Agent)Sr NoNameOperation SinceAvg O/S 12 MonthTotal Sale Last 12MNo Of Months Not PurchaseTotal O/SAbove Days O/S123Any Other InformationSignature Of Depot Manager / C&F Agent With Date MARKET COVERAGE District 1 District 2 District 3 % Sale to Wholesale % Retail Sales No. Of Chemists No. Of Nursing Homes No. Of Major Institutions No. Of Blacklisted I/We Declare that above information is true.Applicant Signature Submit Form
