APPLICATION FORM FOR
REGISTRATION OF MANUFACTURER /RETAILER /DISTRIBUTOR/IMPORTER/DEALER /TECHNICIAN DEALING IN ULTRASOUND /IMAGING MACHINES IN MADHYA PRADESH
* Indicates Mandatory Fields
Applicant Details
Applicant Name *
Type Of Facility to be Registered: *


Residential Address
Plot No/House No/Flat No
State District
Tehsil Pin Code
Mobile No Email Id
Office Address
Please Click Here, if office address is same as the residential address
Plot No/House No/Flat No *
State District *
Tehsil * Pin Code *
Mobile No * Email ID *
Organization Details
Type Of Ownership Of Organization *
Product Details
Product's Specification *

Approval Sought For * Description
1.
2.
3.
4.
Equipments/Services available with the Make and Model
S.NoMachine Type *Company Name*Model Name*Type of Repair work Undertaken*  
1
List Of Employees And Dealers
SnoEmployee Name*Employee Experience*Employee Designation*Employee Qualification*  
1
List Of Enclosure
1. Light Bill/Telephone Bill/Tax Bill for Address
Proof of Residence/office*
.JPG Format of upto 200 kB
2. Photo Identity-Pan Card/Passport/Aadhar/Voter Id
OR Election Commission Card/Driving License*
.JPG Format of upto 200 kB
3. Partnership Deed/Registration Of
Company/Firm Registration Documents*
.JPG Format of upto 200 kB
4. Authorized Dealership certificate/Documents * .JPG Format of upto 200 kB