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Data from Distributors
Please fill out the form to help us gather the stock level data.
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* Indicates required question
Name of the distributor
*
Your answer
Contact person
*
Your answer
Name of companies and divisions, if you have
*
Separate companies and divisions by comma
Your answer
DDA Registration number of the distributor
Your answer
Location of the distributor
*
Your answer
City of Distributor
*
Your answer
District of Distributor
*
Your answer
Mobile Number
*
Your answer
Landline number
*
Your answer
Email address
Your answer
Which drugs are you in short supply, if any?
*
Separate each name by a comma. Put NA if no short supply
Your answer
Remarks/ Other Comments?
Your answer
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