Proposed Stockiest Name (To be filled in by ZSM/DSM/RSM Only) (To be Filled in by Depot/C&F Agent) Sr No Name Operation Since Avg O/S 12 Month Total Sale Last 12M No Of Months Not Purchase Total O/S Above Days O/S 1 2 3 Any Other Information Signature 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
