Research.net Powered Online Survey

CoVaD

Corporate Vaccine Demand

You are requested to fill in the details below to help us consolidate the industry demands.

It should be noted that the distribution may be rationed as per the availability of the vaccine.

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* Details of the Company

Company Name *

Corporate Address *

Address 2

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* State / Union Territory

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* Is your company

CII Member

Affiliate Association of CII

Member of YI, IWN, IGBC, etc. (specify)

Not a member

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* Details of the contact person from your company

Name

Designation

Email Address

Phone Number

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* Enter the City where you have Vaccine requirement
Select the city from the drop-down

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* Contact Details

Name of the contact person at this location

Mobile no. of contact person at this location

Email of contact person at this location

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* No. of Single dose vaccine required for above location
(Please enter number in figures)

For Employees

For Family members of employees

For Community (Social Development)

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* Enter the 2^nd City where you have Vaccine requirement
Select the city from the drop-down

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* Contact Details

Name of the contact person at this location

Mobile no. of contact person at this location

Email of contact person at this location

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* No. of Single dose vaccine required for 2nd location
(Please enter number in figures)

For Employees

For Family members of employees

For Community
(Social Development)

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* Enter the 3^rd City where you have Vaccine requirement
Select the city from the drop-down

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* Contact Details

Name of the contact person at this location

Mobile no. of contact person at this location

Email of contact person at this location

Question Title

* No. of Single dose vaccine required for 3rd location
(Please enter number in figures)

For Employees

For Family members of employees

For Community
(Social Development)

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* Enter the 4^th City where you have Vaccine requirement
Select the city from the drop-down

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* Contact Details

Name of the contact person at this location

Mobile no. of contact person at this location

Email of contact person at this location

Question Title

* No. of Single dose vaccine required for 4th location
(Please enter number in figures)

For Employees

For Family members of employees

For Community
(Social Development)

Question Title

* Enter the 5^th City where you have Vaccine requirement
Select the city from the drop-down

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* Contact Details

Name of the contact person at this location

Mobile no. of contact person at this location

Email of contact person at this location

Question Title

* No. of Single dose vaccine required for 5th location
(Please enter number in figures)

For Employees

For Family members of employees

For Community
(Social Development)

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* Do you want to submit details for more locations?

Yes

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* Details of the Company

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* State / Union Territory

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* Is your company

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* Details of the contact person from your company

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* Enter the City where you have Vaccine requirement Select the city from the drop-down

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* Contact Details

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* No. of Single dose vaccine required for above location (Please enter number in figures)

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* Enter the 2nd City where you have Vaccine requirement Select the city from the drop-down

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* Contact Details

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* No. of Single dose vaccine required for 2nd location (Please enter number in figures)

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* Enter the 3rd City where you have Vaccine requirement Select the city from the drop-down

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* Contact Details

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* No. of Single dose vaccine required for 3rd location (Please enter number in figures)

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* Enter the 4th City where you have Vaccine requirement Select the city from the drop-down

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* Contact Details

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* No. of Single dose vaccine required for 4th location (Please enter number in figures)

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* Enter the 5th City where you have Vaccine requirement Select the city from the drop-down

Question Title

* Contact Details

Question Title

* No. of Single dose vaccine required for 5th location (Please enter number in figures)

Question Title

* Do you want to submit details for more locations?

* Enter the City where you have Vaccine requirement
Select the city from the drop-down

* No. of Single dose vaccine required for above location
(Please enter number in figures)

* Enter the 2^nd City where you have Vaccine requirement
Select the city from the drop-down

* No. of Single dose vaccine required for 2nd location
(Please enter number in figures)

* Enter the 3^rd City where you have Vaccine requirement
Select the city from the drop-down

* No. of Single dose vaccine required for 3rd location
(Please enter number in figures)

* Enter the 4^th City where you have Vaccine requirement
Select the city from the drop-down

* No. of Single dose vaccine required for 4th location
(Please enter number in figures)

* Enter the 5^th City where you have Vaccine requirement
Select the city from the drop-down

* No. of Single dose vaccine required for 5th location
(Please enter number in figures)