ESIC e-TENDER ENQUIRY FORM FOR DG ESIC AYURVEDIC RATE CONTRACT No. Ay-10 FOR SUPPLY OF AYURVEDIC DRUGS

Firm Name and Address

Total No. of the Drugs quoted

DETAILS OF THE DRUGS / ITEMS QUOTED

(To be uploaded in Excel as well as PDF uploaded)

Description asked for in the tender Offer made by the firm

SI. No Drug Code Drug Name & Description Packing as required Drug Name and Description of the product & Brand Name in case of drug as per Disease Category Packing offered Drug Licence No. & Date of issue for the product Date of Mfg. of 1st batch of the product SI. No. in Annexure-B-I & B-II /page no. Was a firm debarred in the past for the items if so, provide detail Remarks

Manufactured by Marketed by Type of Drug Licence Self mfg. / loan licence / 3rd party Remarks (Put NA if not applicable)

(To be uploaded in Excel as well as PDF uploaded)

Name of the Firm:

Tender Enquiry No:

Earnest Money Deposit Criteria

S.No. Item Code Name of Drugs Drugwise EMD (in Rs.) as per the Drug Schedule

Sum total of EMD submitted in Rs.

Signature of Authorized Signatory:

NOTE: Correct Item No. & Name of the Drugs to be mentioned.

(To be uploaded in excel as well as PDF)

Name of the Firm:

Type of Firm (General, MSE & Start up):

Turnover for Financial Years 2022-23, 2023-24 & 2024-25

Details of the sales Turnover for Ayurvedic Drugs Financial Year 2022-23 (In Rupees) Financial Year 2023-24 (In Rupees) Financial Year 2024-25 (in Rupees)

Annual Turnover of all Ayurvedic Drugs and their formulations

Total number of items Quoted

Total Annual Turnover of the firm for Quoted drugs and their formulations for the year 2022-23

Total Annual Turnover of the firm for Quoted drugs and their formulations for the year 2023-24

Total Annual Turnover of the firm for Quoted drugs and their formulations for the year 2024-25

Average Turnover of Quoted drugs and their formulations (in Rs.) for the last 3 years

Signature of CA:

Registration No. :

NOTE: Correct Item No. & Name of the Drugs to be mentioned.

Select, Excess (+), Less (-)

Tender Inviting Authority: DIRECTOR GENERAL, EMPLOYEES' STATE INSURANCE CORPORATION

Name of Work: SUPPLY OF AYURVEDIC DRUGS

Contract No: E-TENDER ENQUIRY FORM FOR DG ESIC AYURVEDIC RATE CONTRACT NO. AY-10

Name of the Bidder/ Bidding Firm / Company :

Sl. No. Drug Name & Description Drug / Item Code as in T.E Quantity Packing Size Required Estimated Rate in Rs. P Addition / Deduction Addition / Deduction Values Currency Convertion against each Item Quoted Currency in INR / Other Currency Net Rates offered per Pack (in figures) Net Rates offered per Pack (in words ) Applicable GST Brand Name in case of drugs as per disease category (Enter NA If not Applicable) Packing Offered *Retail Sale Price exclusive of GST IIIrd Party i.e DGS&D / RITES etc Inspection Charges @0.34%+Service Tax in Rs. P Less for Cenvat Credit,if any respect of Supplies Under full Excise Duty Category in Rs. P

1 Brahmi Vati (Mukta Yukta) - A.F.I. SYS-1 0.000 2 gm/20 tab Excess(+) Full Conversion INR

65 Ayush Kwatha Churna - A.F.I. KK-1 0.000 100 gm Excess(+) Full Conversion INR

129 Gandhak Mishran - A.F.I. MK-2 0.000 10 gm/40 tab Excess(+) Full Conversion INR

193 Mutrashmari Hara Liquid/Syrup (Sugar Free) UD-6 0.000 100 ml Excess(+) Full Conversion INR

257 Rasayana Avaleha RGD-4 0.000 250 gm Excess(+) Full Conversion INR

Total in Figures

Quoted Rate in Figures Select, Excess (+), Less (-) %

Quoted Rate in Words

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