SPECIMEN APPLICATION FORM FOR REGISTRATION OF FIRMS IN EASTERN RAILWAY (MEDICAL DEPARTMENT)
To
Chief Medical Director,
Eastern Railway,
14-Strand Road.(12th floor),
Kolkata-700001.
Sub: -
Request application for Registration of the firm at Eastern Railway (Medical Department)
~~~~~
I/We the undersigned the authorized signatory/signatories for the firm, request for Registration of our firm at
Eastern Railway (Medical Department) as per the terms and condition laid and amended till date. We are hereby
furnishing all relevant information and enclosing all the relevant records along with this application.
1. Name of the firm need to be Registered.
2.
Postal address of the Head Office along with Fax Contact Phone No.
Website & Email ID.
3.
Postal address of the Regional/Branch Office nearest to Kolkata
along with Fax, Contact Phone No., Website & E-mail ID.(if HQ is
somewhere else)
4.
Postal address along with Fax, Contact Phone No., Website & Email
ID of the Manufacturing Units, products of which are Marketed by
the firm along with the inspection details of those units by railways:
5.
No. of years of Standing in the Manufacturing and Marketing of the
firm for the products which need to be Registered to each of the
Manufacturing Units ( Table format)
6.
WHO-GMP certificate issued by the competent authority to each of
the Manufacturing Units with validity.
7.
Drug License issued from the competent authority to each of the
Manufacturing Units with validity.
8.
ISO 9000 certificate issued by the competent authority to each of
the Manufacturing Units with validity.
9.
‘Non Conviction’ certificate issued by the competent authority to
each of the Manufacturing Units with validity.
10. ‘Market Standing’ Certificate issued by the competent authority to
each of the Manufacturing Units with validity.
11. ‘Performance’ Certificate issued by the competent authority to
each of the Manufacturing Units with validity.
12. Latest Ranking as per ORG-MARG NIELSEN of Individual
Products/Brands.
13. Latest Ranking as per National/Central Health Ministry report.
14. Name of the other Railways where the firm is Registered (may
enclose photo copy of valid certificates).
15. Name of the other Government Institutions where the firm is
Registered.
16. Average Turnover of the previous three years from the
Manufacturing and Marketing of the own domestic products of the
firm.
17. Items found Sub/Non Standard within previous three years.
Contd. P/2
-: P/2:-
Continuation of Specimen of Application form for Registration of firms in Eastern Railway (Medical Department)
I/We have enclosed the following documents in support of the above mentioned information.
1.
2.
3.
Sl.
No.
4.
Notary attested documents in support of item No.5 to 15
Notary attested copies of financial results of the previous three years and ‘Turnover Certificate’ of the previous
three years issued from Chartered Accountant in support of item No.16
The products list as per the list mentioned below which contain only the brands available in open market for
retail sale in the region of Eastern Railway ( Table Format Preferable as shown below)
Generic Name, strength,
IP/BP/USP
Trade Name
/ Brand
Mfg. Unit
MRP
Market
Standing
Latest ORG MARG
Ranking, if available
Validity of WHOGMP of the item
Documents for products imported from foreign countries need to be Notary attested.
I/We hereby declare that
1. I/We do hereby declare that the there is ‘No Major Punitive Action taken/Contemplated against our firm by
any Zonal Railways/Central Government/State Government’ and if the information provided is found wrong
my/our firm can be de-listed for three years all over Indian Railways.
2. I/We do hereby declare that the products being applied b y our firm for Registration are available in open
market for retail sale of same brand in the region of Eastern Railway.
3. I/We do hereby declare that the, I/We agree for inspection to be carried by your officials for the all
Manufacturing units located in your Railways for the products Marketed by our firm before confirmation of
Registration, if not done already.
4. I/We do hereby declare that the, I/We agree to the all Tender Conditions of Medical Department of Eastern
Railway as amended till date and that the Final Decision for Registration of the firm lies with your Railways.
5. I/We do hereby declare that the, I/We agree to pay Rs.5, 000.00 (Five thousand) on intimation from your
Railways as Registration fees charged for three years.
6. I/We do hereby declare that the, all future changes in the constitution or working of the firm, affecting the
accuracy of the information now given would be promptly communicated to your office.
7. I/We do hereby declare that the entries made in this application form are true to the best of my/our
knowledge and also that we shall be bound by the acts of my/our duly constituted attorney.
Authorized Signatory of the firm.
(Full Name with Stamp of the firm)