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BHARTAM
(A Company with Indian Heart & Global Vision)
BHARTAM REPRESENTATIVE REGISTRATION
(* Field is mandatory)
Representative Photo
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Referral Code
*
Representative Personal Details
First Name
*
Middle Name
Last Name
Date of Birth (DOB)
*
Gender
*
Select Gender
Male
Female
E-mail Id
*
Mobile No.
*
Alternate Mobile
Whatsapp No.
*
Nationality
*
UID/Aadhar Card No.
*
Pan Card No.
*
Representative Contact Details
Address
*
Village
*
Post
*
Tehsil
*
Country
*
State
*
Select State
Andra Pradesh
Arunachal Pradesh
Andaman and Nicobar Islands
Assam
Bihar
Chandigarh
Chhattisgarh
Dadar and Nagar Haveli
Daman and Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadeep
Madya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Pondicherry
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttaranchal
Uttar Pradesh
West Bengal
Telegana
District/City
*
Pincode
*
Representative Family Details
Father Name
*
Mother Name
*
Husband/Wife Name
Representative Banking Details
Account No.
*
Confirm Account No.
*
Account Holder Name
*
IFSC Code
*
Bank Name
*
Branch Name
*
Representative Other Details
Shop Name
Shop Address
GST No.
FSSI No.
Drug License No.
Registration No.
Buisness Nominee Name
*
Nominee Relation
*
Distributor Name
*
Select Distributor Name
Bhartiya Aushadhiya Kendra
Mahi Medical Agency
Anant Traders
Submit
