Name of Firm:
Name of Concerning Person:
For Billing
Address :
City
District
State
Pin Code
For Correspondence if change
Contact Detail: Mobile No 1
Mobile No 2
Phone No / Fax No. : Land Line No.
Your email
Date of Birth
D.L. No.:
GST No.:
Area of Operation (Define by Distt. Place):
Date & Detail of Franchisee Deposit Amount or Cheque:
Your Interest in Segment of Products (Tick Mark only) Louies Life ScienceLouies RespiraVenz LifeLouise ChhronicMOM division
Mansion you’re Preferred Courier and Transport Name Courier Name:
Transport Name:
Against to franchisee deposit we will give you welcome kit (Bag, Visual-Ad, Promotion material , Stationery for Promotion )
Date:
Name
Note: 1. This form is applicable for Luckys Pharma and its all Divisions, Terms & Conditions which is send by us to you with our Price List.
