Community Development Medicinal Unit West Bengal

ORDER FORM FOR MEDICINES AND MEDICAL SUPPLIES
Date :	Order No. :
Name of the Organisation :
Delivery Address :
Contact Person :	Telephone :
Email: List of medicines / medical supplies Sl No Item Name Pack Quantity Remarks 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Instructions (if any):
Name of the Authorized Person :
Send this form to: Select from the list : Kolkata office Siliguri office
Please fill-in the online version of this form or fill-in the print version and mail it to: The Chief Manager, Community Development Medicinal Unit, 86C Dr Suresh Sarkar Road, Kolkata - 700 014 or to The Adminsitrative Officer, Community Development Medicinal Unit, East Vivekananda Pally, Raja Rammohan Roy Road, P.O. Rabindra Sarani, Siliguri - 743 406.