empanelment of drug testing laboratories - Kerala Medical Services ...

APPLICATION FORM
ANNEXURE – II
Ref.Clause No.5.10.10
[Note: - The following details filled in this form must be accompanied by sufficient
documentary evidence, in order to verify the authenticity and correctness of the
information.]
Sl.No. Particulars Details (To be filled in by the EOI Responder)
1 Name of the Organization
Address(Regd. Office):
Telephone:
Fax:
E-mail:
Website:
2 Name of the Contact
Person:
Telephone:
Mobile:
E-mail ID:
3 Type of the Organization
(Public Sector/Limited/
Private Limited/Partnership/
Proprietary/Any Other):
4 Chief Officer of the
Organization:
E-mail ID:
Telephone:
5 Registration No. & Date of
Incorporation of Company:
6 License No. & Date for
conducting the Analysis.
7 PAN no:
8 Activities of the organization:
(Briefly List)
9 List of 3 Clients as per clause
KMSCL: EOI for Empanelment of Drug testing Laboratories Page 35