APPROVAL SEET FOR INSTITUTIONAL SUPPLIES Product I Product II

Sr.No. PARTICULARS Pentaxim Okavax

1 Name of the Hospital/Institution :
2 Product to be supplied
3 Quantity to be Supplied
4 Validity period of the approval : till december
5 Is it order specific or period specific
6 Supplies will be made through (Name of stockist):
7 Rate on which it will be billed to stockist (excluding taxes):
8 Rate on which stockist will supply to the institution/hospital:
9 Margin proposed for stockist in rupee value:
10 Over riding Commission percentage*
* Over riding commission will be calculated on supply rate by SPI to Stockist
total C N Required

VERIFIED BY VALIDATED BY RECOMMENDED BY APPROVED BY APPROVED BY

(ASM) (RBM) (NSM) DIRECTOR SALES DIRECTOR SUPPLY
Product VI
menomune
gamca center
menomune
200
till dec 31st
period
Quality vaccines
3542
3250
8%+7%
CLAIM SHEET
Claim No.
Month :October Name & place of Stockist: AMY PHARMA

Over Over
Rate Riding Riding
Supply Approve Differen Commis Commi
Rate to Invoice d Rate ce sion ssion
Supply Rate to Hospital/In No.of Differen Claim Percenta Amoun
Sr.No.Name of Hospital/Institution
Product Supplied
stockist* stitute Stockist Date Qty. ce (HxJ) ge t
FSI000873/ 30/08/2010,2
FSI000923 8/10/2010
1 Gamca Menomune 3542 3542 200 8% 56672
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

IMPORTANT :
1. Stockist will be required to submit the copy of the order of the institution
2. Order copy will be signed & stamped by the stockist
3. Acknowledged copy of invoice received from institution will have to be
enclosed with the claim of rate difference
4. All the documents will be signed by the RBM
5. Only one claim per month will be entertained
6. Stockist will be required to submit claim by 7th of subsequent month to the ASM
7. VAT difference will not be covered/reimbursed as per group policy

SIGNATURE OF ASM
SIGNATURESIGNATUREOF
OF RSM NSM

DIRECTOR SUPPLYASSOCIATE
CHAIN DIRECTOR FINANCE
Total
Claim
(J+L)

56672
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 APPROVAL SHEET FOR INSTITUTIONAL SUPPLIES Product I Product II
Sr.No. PARTICULARS Pentaxim Okavax
1 Name of the Hospital/Institution : ABC Hospital Ludhiana
2 Product to be supplied Yes
3 Quantity to be Supplied: For all supplies during validity period
4 Validity period of the approval : From 1.4.2010 to 31.3.2011
5 Is it order specific or period specific : Period Specific
6 Supplies will be made through (Name of stockist): Vaccine Junction Chennai
7 Rate on which it will be billed to stockist (excluding taxes) 1280
8 Rate on which stockist will supply to the institution/hospital 1330
9 Margin proposed for stockist in rupee value: 50
10 Over riding Commission percentage* 3%
* Over riding commission will be calculated on supply rate by SPI to Stockist

VERIFIED BYPROPOSED BY VALIDATED BY APPROVED BY APPROVED BY

(ASM) (RBM) (NSM) DIRECTOR SALES DIRECTOR SUPPLY
CHAIN
 Product III Product IV Product V Product VI
Imovax Polio Pneumo23 Tripacel Vaxigrip

Yes Yes

700 500
800 570
100 70
4% 2%

APPROVED BY
ASSO. DIR.
FINANCE