Please fill all the fields and share any details that you would like. Thank you!
(This form is confidential and will serve as basis for your company’s evaluation as franchise in your area)

NAME OF COMPANY’S REPRESENTATIVE

CONTACT NO.*

EMAIL ADDRESS*

COMPANY NAME*

COMPANY TYPE*

COMPANY ADDRESS*

WHAT AREAS / REGIONS / DISTRICTS DO YOU WANT THE PRODUCTS FOR?*

PHARMA SALES EXPERIENCE / AGE OF COMPANY

YOUR COMPANY’S AVERAGE SALES / MONTH (IN USD)

COMPANIES IN CONTRACT WITH

ADDITIONAL DETAILS

INTERESTED IN WHICH OF OUR PRODUCTS?

FoliPill Tablets
LCZEE TABLETS
Mel Plus