Aplication Form (*) All are compulsory fields.
Kindly Fill and Submit It
1. Applying for :
*
2. Which software you are intrested in ?
 
Select Main Product & Then Select Its Sub Products.     









Select Sub Product List.
 
3. Select this online Softwares for Marketing.



 
4. Name of your company :
5. Please Indicate the type of your company /Background.




 
6. Contact Person :
*
7. Designation / Title / Position :
8. Business Address/Personal Address :
9. Country :

State :

City :
*
*
*
10. Pin/Zip : *
11. Telephone No :
12. Cell / Mobile No :
Cell 1: *
Cell 2:
Cell 3:
13. Fax No :
14. Email :

Web :		 *
 
15. For which Area / State / City are you planning to take up a Marketing Agent/Distributorship/Dealership/IBA  ?
16. How will you finance your business? (Tick Appropriate).

17. How much finance you can invest ? *
18. When would you like to start Birlamedisoft Distributorship / Dealership/IBA ?


*
19. Which online Products you want to sale ?
20. Do you have an office ?
21. Address of the operating office :
*

22. Office size in sq.ft :
23. How many staff currently employed including you?
24. Staff details  :
How Many :
How Many :
How Many :
25. Would you be willing to appoint a Sales & Services staff exclusively for Birlamedisoft ?
26. Kindly mention Bank Details,Name of your bankers
  * Name of the Bank :
  * Branch :
  * Bank Account No :
27. Do you have TIN No or PAN No.(Tax Nos)
  * TIN No  :
  * PAN No :
28. Do you own Laptop Computers? (Tick Appropriate).
  How Many ? Nos.
29. Name of contact person at your place  :
30. Why are you interested to get Birlamedisoft Product Marketing ?
31. What is your vision if you are accepted & approved as a  Birlamedisoft Product Marketing ?
32. How would you like to Market & Sale Birlamedisoft Medical Software products to make a viable and successful  Product Marketing ?
33. Do you want your name to appear on birlamedisoft.com website ?
34. Kindly attach your Company's Profile.(If any)
35. Any Remark ?
36. Type the city names in which you will carry out Birlamedisoft    Product Marketing.
*
   Note : Enter city names seperated by','.
   ( eg  :  Pune,Banglore,Mumbai. etc.)
 

I / We clearly state that I / We are interested to take up  Birlamedisoft  Product Marketing.

I / We state, that the above information provided here is true and correct to  the best of my / our knowledge.
                                                                                                                                                                                      
 Type Your Name
 
*