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Apply For Distribution

Name of the Organisation

Complete Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Office No.

Residence no *

Corporate Status

A. Shir/Smt

Phone

B. Shir/Smt.

Phone

GST No.

PAN Card No.

Adhaar Card No.

8. Is the Company/Firm authorized dealer and distributor for any other company? Yes/ No. If yes, please specify details mentioned here under:

Company Name

Product Name

From

Till

Company no 2.

Product Name 2.

From Date no 2. *

TIll Date No 2.

Present Turnover Of the Firm/co .(RS)

Total No of Employees

I/we hereby declare that the above mentioned information is true and correct to the best of my knowledge and belief. Nothing has been concealed or any false declaration has been made, our appointment shall be liable to termination without notice.

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