Eisen_logo

PSR_Sample_Request_Form

  1. Fill this form to submit your Phy. Samples requirement for next sampling cycle
  2. Additional samples allocation will be considered, if you are planning sales above your target
  3. Your samples will be dispatched considering your submitted requirement & according to your current sales/sample ratio (ideal is 10)
  4. Mention " 0 " if you do not require samples of any product
  5. * Represents Mandatory Fields

Select Sampling Cycle *        

PSR Name *                            

PSR HQ * (as per I-CAN)     

Reporting ASM HQ                

Reporting ZSM HQ                



                                          * Mandatory Fields
Product
 Samples Required * (Units)
 Sale Planned *
for the sampling cycle (Units)
1) ALKORINA syp - * 

2) ANAPROTIN syp - *
3) ARTICULIN FORTE tab - *
4) CALBISIX chu tab - *
5) CALBISIX 500 tab - *
6) CALBISIX syp - *
  7) CLOXMOX 500 cap - *
8) COLDGUARD Xt tab - *
9) COLDGUARD Xt susp - *
10) SUCCIRON cap - *
11) ULTRAFOLIN tab - *
12) ULTRAFOLIN MBA cap - *
13) ULTRAFOLIN 5 tab - *
14) ZIRRO 500 tab - *
15) ZIRRO 100 susp - *
16) COUGHOREX syp -
17) DEXBRO syp -
18) EUCRASIL tab -
19) FENUZYME tab -
20) ZENPLEX Cap -
 
                                Anything More...