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Goverment of Madhya Pradesh
Department of Public Health & family Welfare
APPLICATION FORM FOR
REGISTRATION OF MANUFACTURER /RETAILER /DISTRIBUTOR/IMPORTER/DEALER /TECHNICIAN
DEALING IN ULTRASOUND /IMAGING MACHINES IN MADHYA PRADESH
*
Fields Marked with * are Mandatory
Applicant Details
Applicant Name
*
Type Of Facility to be Registered:
*
Manufacturer
Retailer
Distributor
Importer
Refurbisher
Dealer
Technician of Ultrasound/Imaging Machine
Residential Address
Plot No/House No/Flat No
State
Select
ARUNACHAL PRADESH
ASSAM
ANDAMAN AND NICOBAR ISLANDS
ANDHRA PRADESH
BIHAR
CHHATTISGARH
CHANDIGARH
DAMAN AND DIU
DELHI
DADRA AND NAGAR HAVELI
GOA
GUJARAT
HARYANA
HIMACHAL PRADESH
JHARKHAND
JAMMU & KASHMIR
KARNATAKA
KERALA
LAKSHADWEEP
MEGHALAYA
MANIPUR
MADHYA PRADESH
MAHARASHTRA
NAGALAND
ORISSA
PUNJAB
PONDICHERRY
RAJASTHAN
SIKKIM
TRIPURA
TAMIL NADU
UTTARAKHAND
UTTAR PRADESH
WEST BENGAL
District
Select
Tehsil
Select
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
Select
ARUNACHAL PRADESH
ASSAM
ANDAMAN AND NICOBAR ISLANDS
ANDHRA PRADESH
BIHAR
CHHATTISGARH
CHANDIGARH
DAMAN AND DIU
DELHI
DADRA AND NAGAR HAVELI
GOA
GUJARAT
HARYANA
HIMACHAL PRADESH
JHARKHAND
JAMMU & KASHMIR
KARNATAKA
KERALA
LAKSHADWEEP
MEGHALAYA
MANIPUR
MADHYA PRADESH
MAHARASHTRA
NAGALAND
ORISSA
PUNJAB
PONDICHERRY
RAJASTHAN
SIKKIM
TRIPURA
TAMIL NADU
UTTARAKHAND
UTTAR PRADESH
WEST BENGAL
District
*
Select
Tehsil
*
Select
Pin Code
*
Mobile No
*
Email ID
*
Organization Details
Type Of Ownership Of Organization
*
Select
Company
Co-Operative
Indvidual
Others
Partnership
Product Details
Product's Specification
*
Colour Dopplers
Other
UltraSound Scanners
Approval Sought For
*
Description
Product
Merchandise
Services
Others (Specify)
Equipments/Services available with the Make and Model
S.No
Machine Type
*
Company Name
*
Model Name
*
Type of Repair work Undertaken
*
1
List Of Employees And Dealers
Sno
Employee 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
CVRAMAN