Application No. ___________
Affiliate / Franchise
Application Form
1 .Franchise Trade Name :
_____________________________________________________________________
2. Address : ___________________________________________________________________________
3. Street / Village : ___________________________________________________________________________
4. City : _______________________________________
4A. State _ ___________________
5. Contact Person : ____________________________________________________________
6. Father’s Name / Husband’s Name : _____________________________________________
7. Gender Male__________________________________Female______________________
8. Date of Birth ______________________________________________________________
9. Mobile Number : _______________________9A. Land Line
Phone No. _ _______________
10. Email Id : ________________________________________________________________
11. Designation: Proprietor_______________ Partner _________________________________
12. Bank Name: ______________________________________________________________
13. Bank Address: ____________________________________________________________
14. Account No. : ____________________A/c Type : S/B____________________________
15. RTGS / IFSC Code No. : _ __________________________________________________
16. .PAN _ ___________________________ TIN
__________________________________
17. VAT No.
________________________________________________________________
18 Recommended by Area
Manager Name _________________________________________
I hereby declare that the above facts are true to the best of my
knowledge. I hereby confirm that, I have read the terms and condition and
accept the same.
AM Signature:
Date ____________ Place______________
Seal & Signature of Franchise/ Affiliate
___________________________________________________________________________
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