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Application For Glocal Digital Dispensary: A. For Office Use | PDF | Identity Document | Loans
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Application For Glocal Digital Dispensary: A. For Office Use

This document is an application for a franchise to operate a digital dispensary. [1] It requests background information on the applicant such as name, address, education, work experience and references. [2] It also asks for details on the proposed dispensary such as location, facilities, financing breakdown and property details. [3] The applicant declares the information provided is true and acknowledges any false information could result in cancellation of the franchise.

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Mohd Sharim
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121 views3 pages

Application For Glocal Digital Dispensary: A. For Office Use

This document is an application for a franchise to operate a digital dispensary. [1] It requests background information on the applicant such as name, address, education, work experience and references. [2] It also asks for details on the proposed dispensary such as location, facilities, financing breakdown and property details. [3] The applicant declares the information provided is true and acknowledges any false information could result in cancellation of the franchise.

Uploaded by

Mohd Sharim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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APPLICATION FOR GLOCAL DIGITAL DISPENSARY

A. For office Use:

Entrepreneur Name Application Place Category Date


Sl. No. Individual/Group

B.Business Information:

Name of the
Company
/Entrepreneur

Current Business
Address State PIN Code
Business Premises √ Rented Owned
Telephone No. Mobile No. 91
Residential
address
E-mail:
Business Existing
Activity
Date of Commencement(DD/MM/YYYY)
Whether the Unit is Registered √ Yes No
If Registered (Please mention:Registration no. And
the Act under which registered )
Registered office Address
Minority
Social Category √ General SC ST OBC
Community
If Minority
√ Buddhists Muslims Christians Sikhs Jains Zoroastrians Others
Community
C.Background Information:
S.No Name Date Sex Residential Academic Work Experience Experience
of Address with Qualification in Health
Birth Mobile No. Type of
No of years (Years)
experience
1.
2.
3.

S.No Id proof Id proof no. Address proof Address proof no. PAN Card/DIN No.

1. AADHAR CARD
2.
[Document title]

E. Banking FacilitiesExisting:

Sl.No. Bank Name, address Savings Account Current Account

1.
√
2.
Sl No Type of loan Lender Amount o/s
1.
2.

F. Project Financing Break UP - Proposed:(In Rs.)

Means of finance for Type of Investment Cash/FD Details


Amount
the project Personal loan etc
Own investment
Bank Loan

G. Property Detailsfor proposed Digital Dispensary

Sl.No Address Area Type Period of Agreement if Facility


(Sqft) Own/Rented/leased rented/leased Water Toilet Electricity Internet
1.
√
2.

H. References

Sl.No Name Address Phone Occupation Relationship


with applicant
1.

2.

DECLARATION

I hereby certify that the information stated above are correct and true to my knowledge and belief and hereby confirm that
im not a defaulter of any loan nor convicted in any litigation. I accept that any facts stated above, If found incorrect will
automatically result in cancellation for franchisee.

Name:

Signature:

Date & Place:

Documents attached: (√)


Passport Aadhaar Letter/Card* Copy of last academic qualification*
Voter's Identity Card* NREGA Card Copy of Ownership/lease/rent document for the premises*
Driving Licence PAN Card* SC/ST/OBC certificate
Address proof of residence* *Compulsory

2
[Document title]

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