Department of Commercial Taxes SUPPLIER REGISTRATION FORM To The Director, JIPMER, Pondicherry-6. Sub: Supplier Registration - Reg. *** Sir, With reference to the above, we are submitting/enclosing the details as mentioned below: Name of items / Services (apply separately for each Category) for Registration : (mention category, Sl. No. & name of items and services) 1 1 Name of the Firm: PAN : C.S.T No./ VAT No.: Registration No.: Income Tax Return : (attach Photocopies) 2 Authorized Agent for foreign items Manufacturer: Agent/Stockist for Indian items: Suppliers within 300Km radius from Pondicherry: Yes / No (If yes enclose copy for authorization) Yes / No (Provide/ Furnish list of items manufactured) Yes / No (If yeas enclose copy of letter appointing you as Agent/Stokist) Yes / No 3 Address: Telephone No.: Cell No.: E-mail address: Fax No.: Bank Account Details: Branch IFSC Code/Type of Bank Account with Account No. & MICR Code of Bank: 4 Status: Public / Pvt. Ltd., /Partnership: S.S.I. / Whether Registered with DGS&D/ Name & address of Partner: Nature of business & Banker : (attach Photocopies) 5 Documentary evidence in r/o Manufacturing capability, quality control systems, past performance, after-sales services, financial background, manufacturer / authorization, work order / supply order, List of customers, No Conviction Certificate etc., (attach Photocopies) 6 Address of Service Centre/ Local Office with Telephone No.: Cell No.: /E-mail No. : reg. AMC/CMC/Repair jobs 7 We wish to register to supply or service the items 1.Category-A Sl.Nos._______ 2.Category -B Sl.Nos._______ : Note: Use separate sheets, if space is inadequate Signature Rubber Stamp of Firm For office use only: Recommended / not recommended for registration. Approved by Director, JIPMER, Pondicherry-6
