APPLICATION FOR GLOCAL DIGITAL DISPENSARY

A. For office Use:

Entrepreneur Name Application Place Category Date

Sl. No. Individual/Group

B.Business Information:

Name of the
Company
/Entrepreneur

Current Business
Address State PIN Code
Business Premises √ Rented Owned
Telephone No. Mobile No. 91
Residential
address
E-mail:
Business Existing
Activity
Date of Commencement(DD/MM/YYYY)
Whether the Unit is Registered √ Yes No
If Registered (Please mention:Registration no. And
the Act under which registered )
Registered office Address
Minority
Social Category √ General SC ST OBC
Community
If Minority
√ Buddhists Muslims Christians Sikhs Jains Zoroastrians Others
Community
C.Background Information:
S.No Name Date Sex Residential Academic Work Experience Experience
of Address with Qualification in Health
Birth Mobile No. Type of
No of years (Years)
experience
1.
2.
3.

S.No Id proof Id proof no. Address proof Address proof no. PAN Card/DIN No.

1. AADHAR CARD
2.
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E. Banking FacilitiesExisting:

Sl.No. Bank Name, address Savings Account Current Account

1.
√
2.
Sl No Type of loan Lender Amount o/s
1.
2.

F. Project Financing Break UP - Proposed:(In Rs.)

Means of finance for Type of Investment Cash/FD Details

Amount
the project Personal loan etc
Own investment
Bank Loan

G. Property Detailsfor proposed Digital Dispensary

Sl.No Address Area Type Period of Agreement if Facility

(Sqft) Own/Rented/leased rented/leased Water Toilet Electricity Internet
1.
√
2.

H. References

Sl.No Name Address Phone Occupation Relationship

with applicant
1.

2.

DECLARATION

I hereby certify that the information stated above are correct and true to my knowledge and belief and hereby confirm that
im not a defaulter of any loan nor convicted in any litigation. I accept that any facts stated above, If found incorrect will
automatically result in cancellation for franchisee.

Name:

Signature:

Date & Place:

Documents attached: (√)

Passport Aadhaar Letter/Card* Copy of last academic qualification*
Voter's Identity Card* NREGA Card Copy of Ownership/lease/rent document for the premises*
Driving Licence PAN Card* SC/ST/OBC certificate
Address proof of residence* *Compulsory

2
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