Request edit access
TAJ Pharmacy On-boarding Form
Email address *
Pharmacy Name
Pharmacy Location
Pharmacy City
License No.
Pharmacy Timings
Contact Person Name
Contact Person Number
Contact Person Email
Open for Medicine Delivery in Nearby locations?
Medicine Delivery Coverage Radius
Are You Open to Deliver Beyond your Coverage Radius?
Clear selection
Medicine Delivery Start Time
Medicine Delivery End Time
Medicine Delivery Minimum Amount
Medicine Delivery Days?
Medicine Delivery Amount?
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Infiniun. Report Abuse