Sample

APPLICATION FORM
APPOINTMENT OF DISTRIBUTORS
INFORMATION ABOUT YOU
(Please use Capital Letters while filling the form)

1) Name of the Applicant

2) Name of the Business Organization (Proprietorship / Partnership / Pvt. Ltd. Co. / Others)

(Please attach photocopy of Partnership Deed / Memorandum of Association / Article of Association)

3) Constitution of the Distributor

Proprietorship Partnership Others

4) Your Sale Tax Regn. No. :

(Please attach photocopy of RC)

5) Your PAN No. :

(Please attach photocopy of PAN Card)

6) Your Aadhar No. :

(Please attach photocopy of AADHAR Card)

7)
a) Date of Registration/ Incorporation /:
Formation of Business

b) Date of Commencement of Business :

8) Address of the Regd. Office / Principal Place of Business:
(Clearly mention the address with No, Street Name and City with Pin code)

Telephone Nos. :

Fax No. : :
Mobile No. :

Email :

9) Number of Retail outlets covered : Zone_________________

10) Name of Principal Partners / Directors / Proprietor along with their residential address,
educational qualification and Telephone Numbers (Please attach separate Sheet, if required).

Name Age Educational Residential Address & Tel. Status

Qualification Numbers

11) Bank Information

Account Holder Name

Bank Account Number Nature of Account

Branch Name RTGS

12) Business Association

Name Since Product Areas / Town Turn Over Outlets Outlets No of

(Year) Covered (Annual) Available Covered Routes

13) Infrastructure facilities

a) No. of Partners / Directors actively :

looking after the business

b) No. of Sales representatives :

c) Vehicles used for distribution :

S. No Vehicle Type Model Owned/ Hired

d) Godown Address & Telephone Nos. :

Godown Address Contact No Area Insurance

(Sq. Ft) Valid Upto

e) Insurance (Name and Address of the Insurance Company, to which the stocks are proposed to be insured):

Insurance Address of Contact Phone Risk Covered Value

Name Insurance Person
14) Territory (District / Areas / Town for which Distributorship is applied):

Areas / Town Population Approx Outlets

I, S/o declare and affirm that the

above details are true and correct to the best of my knowledge.

Place:
Signature

Date:
Name