STATE BOARDS

West Bengal State Board

CHAIRMAN

Shiv Sagar Tewari (Director)

BURNET PHARMACEUTICALS (P) LTD.

28/5, C. N. Roy Road, 3rd Floor Kolkata-700039

23452426 || 033 - 35038933

sstewari@burnetphama.org || office@burnetphama.org

www.burnetpharma.org

HON. SECRETARY

Siddhartha Paul (Executive Director)

PALSONS DERMA PVT. LTD.

10/D/1, Ho-Chi-Minh Sarani, Kolkata - 700 071.

033-2282 3776 || 033-2282 4278

siddharthapaul71@gmail.com || siddhartha.p@palsonsderma.com

siddhartha.p@palsonsderma.com

Company Name* :

Person Name* :

Address* :

Country* :

State* :

City* :

Pin code* :

Email Id* :

GST No.* :

Mobile No* :

1.Principal Member

Sr No.	Particulars	Annual Membership Subscription	GST @18% ₹	Total Amount ₹

2.Corporate Membership

Sr No.	Particulars	Annual Membership Subscription	GST @18% ₹	Total Amount ₹

3.Associate Company Member

Sr No.	Particulars	Annual Membership Subscription	GST @18% ₹	Total Amount ₹

4.Associate Academic Member

Sr No.	Particulars	Annual Membership Subscription	GST @18% ₹	Total Amount ₹

Membership No :
Company Name :
Expired On :

1.Principal Member

Sr No.	Particulars	Current Membership	Membership Surcharge @20%	Amount	GST @18%	Total

2.Corporate Membership

Sr No.	Particulars	Current Membership	Membership Surcharge @20%	Amount	GST @18%	Total

3.Associate Company Member

Sr No.	Particulars	Current Membership	Membership Surcharge @20%	Amount	GST @18%	Total

4.Associate Academic Member

Sr No.	Particulars	Current Membership	Membership Surcharge @20%	Amount	GST @18%	Total

Address* :

Country* :

State* :

City* :

Pin code* :

Phone No*:

Mobile No* :

Primary Email* :

Secondary Email* :

Departments* :

Ahmedabad( user can select multiple )

Ahmedabad
Surat

Approval	Validity	Delete
Ahmedabad Ahmedabad Surat

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