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RAJIV GANDHI CANCER INSTITUTE & RESEARCH CENTRE
SECTOR –V, ROHINI, DELHI-110 085 PH: 47022222 (30 LINES)
SUPPLIER REGISTRATION FORM FOR THE YEAR-2010 – 2012

Existing Supplier of Rajiv Gandhi Cancer Inst. & Research Centre

Yes

Name of the Supplier

Username

Password

Address of the Supplier

Whether Proprietary Concern/Partnership*

Contact Person Name

Designation

E-mail*

Phone*

Fax*

Product(s) attach separate sheet if required

Whether Manufacturer/Stockiest/Dealer:
Local Agent/Own Facility
(Detail to be attached)

Major Clients (Particularly Hospitals) minimum 2 year supply
(attach separate sheet if required)

Whether authorized for supplying material to Rajiv Gandhi Cancer Inst.& RC
(Attached certificate/authorization letter)

Whether following any environmental/-
quality management system
( ISO 14001/9001)

Yes

Pan No./Tin No/CST No./Service Tax Reg. (No.need certified copy)

Drug License No., if any
(Attach certified copy)

(Compulsory for Drug & Medicine suppliers)

Bank IFSC Code No., Bank Ac. No.*

Any Criminal Case pending against you

Category*

(For selecting multiple Categories hold Control Key and Click on different Items)

I hereby declare that the above particulars are true and correct