Franchisee- SCREENING FORM (Lab Franchisee & Collection Centre Franchisee) of Ranbaxy Medical Services Pvt Limited
To be filled by prospect franchisee
🔴 Please fill this form only if you are interested for New Lab Setup or Transforming your Existing Lab into Branded Lab or Sample Collection Centre
🟢 For New Lab setup Total Cost Approx. ₹ 20-30 Lakhs (Existing Lab No set up cost) 🟢 One Time Brand Fee ₹ 4.99 Lakhs ✅ Revenue Share 94:06 (Franchisee/ Your Share 94% & Ranbaxy MS Share 06% on Gross Value of Business 🟢 For CC new total cost approx.₹0.50 (including CC infrastructure, branding and other cost)
✅ If you agree with above mentioned terms, then only fill this form !
Note : Processing will only start after payment of One Time Brand Fee for Lab Franchisee and CC fee in case of Collection Centre.
Name of Franchise / Client
Status of Client (select)
Please Select
INDIVIDUAL
PARTNERSHIP
HUF
COMPANY
Name of person representing Partnership/HUF/COmpany
First Name
Last Name
SO /DO /WO
Email
example@example.com
Qualification / Brief description about franchisee (Upload certificates/ degree/experience certificates)
PAN Card No. (Upload PAN Card Copy)
ID Proof No. (Upload Copy of Driving License/ Voter ID Card/Passport/Aadhar )
Residence Address with PIN Code (Upload Ration Card, Electricity Bill, Telephone Bill, Aadhar Card, Voter ID)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Premises Address with PIN Code ( Upload Electricity Bill, Telephone Bill, Rent Agreement)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Premises proposed area in Sq Ft ( Length, Width ) example : 150 Sq Ft , Width 15 , Length 10 )
Security Deposit Details ( Cheque No., Bank Amount, Online Transfer Ref.no. Bank Amount)
Photographs of Proposed Premises Uploaded ? (Minimum 05 Photographs required to upload)
Yes
No
File Upload (Upload all files here as requested)
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Client Signature (Sign Here)
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