Neotia Mediplus : Franchise Request Form

033 4040 8000

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Franchise Request Form

Name *

Date of Birth *

Residential Address *

City *

Pincode *

State *

Phone No (Residence) *

Mobile (Whatsapp Number)*

Your Email *

Service / Business *

Name of Company *

Designation *

Phone No (Office)

Do you have a property for franchise ? *

Yes

Property type

Owned

Rent

Lease

Owned Property type

Partnership

HUF

Own

Location of property

I submit the above information is true to the best of my knowledge. I understand that Neotia Mediplus is relying upon all the above information as a material factor in considering my application to become a franchisee for Neotia Mediplus. I agree to supply additional information and statements from my professional associates, as and when required. *

I Accept

Address

Neotia Mediplus OPD & Diagnostics Clinic (A Unit of PARK HOSPITALS)
168, Garia Main Road, Mahamayatala, Kolkata 700084, West Bengal, India

033 4040 8000

frontoffice.g@neotiahealthcare.com

CIN : U85110WB1990NPL049713

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