Consent form for Kadambini

1. Client Code ……….……………………………….

2. Name of the Collection Center ……….………………....……………..

3. Address …………………….…………………..

………………………………………….

4. Pin Code No ……….…………………………………

5. Phone No with STD Code ..………………………………………..

6. Mobile Number ………………………………………….

7. Name of the Contact Person ……….………………………………..

I ……………………………………. hereby confirm our participation in Kadambini Tie-Up

and will offer 10% discount on all the tests (excluding international send out) I Further
understand that above said discounts will be given out of my CC’s margin

Dated: - …………………….. ____________________________

(Signature of the Collection Center)

___________________________
(Stamp)

PS: Please ensure above said form duly signed & stamped should reach to Ms. Shalini
Sharma, Asst. Manager Corporate Communication, Retail Marketing at SRL Ranbaxy,
275/276, Piccadilly House, New Delhi-110065. Phone No- 011-42295365, E-mail-
shalini.sharma@srlranbaxy.co.in on or before 31st August, 06.