Data from Distributors
Please fill out the form to help us gather the stock level data.
Sign in to Google to save your progress. Learn more
Name of the distributor *
Contact person *
Name of companies and divisions, if you have *
Separate companies and divisions by comma
DDA Registration number of the distributor
Location of the distributor *
City of Distributor *
District of Distributor *
Mobile Number *
Landline number *
Email address
Which drugs are you in short supply, if any? *
Separate each name by a comma. Put NA if no short supply
Remarks/ Other Comments?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms