TEKNO THERM Industries
Enrollment Form
Enrollment No
Note:
If you have the existing enrollment number, please enter here to modify the Enrollment Form details
Name of Organization
Organization Category
--Select--
Blood Bank
Clinic
Dental
ESI DISPENSARY
GOVERNMENT HOSPITAL
Hospital
LAB
urban
Address for Communication
City
--Select--
ANAIMALAI
ANNUR
AVINASHI
BANGALORE
BIHAR
CHENNAI
COIMBATORE
COONOOR
DHARAPURAM
JALLIPATTI
KANGAYAM
KARADIVAVI
KOTTUR
KOVAI PUTHUR
MALAYADIPALAYAM
METTUPALAYAM
NEGAMAM-642120
NEW DELHI - 110008.
OOTY
Other
PALLADAM
PERUNDURAI
POLLACHI
RAMANATHAPURAM
SATHYAMANGALAM
SHOLAYAR
SIRUMUGAI
SOMANUR
SULUR
THANJAVUR - 5
THENI
TIRUCHENDUR
TIRUNELVELI
TIRUPUR
UDUMALPET
VALPARAI
VELLAKOVIL
VELLORE
VIRUDHUNAGAR
Pin Code
State
Country
Email ID 1
Email ID 2
Web Site
Organization Contact Details
Phone No 1
Phone No 2
Phone No 3
Fax
Address for Waste Collection
City
--Select--
ANAIMALAI
ANNUR
AVINASHI
BANGALORE
BIHAR
CHENNAI
COIMBATORE
COONOOR
DHARAPURAM
JALLIPATTI
KANGAYAM
KARADIVAVI
KOTTUR
KOVAI PUTHUR
MALAYADIPALAYAM
METTUPALAYAM
NEGAMAM-642120
NEW DELHI - 110008.
OOTY
Other
PALLADAM
PERUNDURAI
POLLACHI
RAMANATHAPURAM
SATHYAMANGALAM
SHOLAYAR
SIRUMUGAI
SOMANUR
SULUR
THANJAVUR - 5
THENI
TIRUCHENDUR
TIRUNELVELI
TIRUPUR
UDUMALPET
VALPARAI
VELLAKOVIL
VELLORE
VIRUDHUNAGAR
Pin Code
State
Country
Phone No 1
Phone No 2
Authorized Person
Name of Account In Charge
Contact No
Name of Purchase In Charge
Contact No
Name of HouseKeeping In Charge
Contact No
Note: 'A','B' & 'C' can be enter with same name and contact no in case no separate person
Authorized Person
Name of Authorized Person
Designation
No.of Beds Installed
In-Charge Name & Contact Details
Name of Account In Charge
Contact No
Name of Purchase In Charge
Contact No
Name of HouseKeeping In Charge
Contact No
Note: 'A','B' & 'C' can be enter with same name and contact no in case no separate person
GPS Coordinates
Longitude
Latitude