DEALERSHIP APPLICATION FORM (PROPOSAL)

Centre:
District:
Application Fees: ------------------------------- (Non Refundable)
Party Name:
Address:

Paste your
Photograph
here

1) Postal:______________________________________________________________________________________
Pin: ____________________At_________________Tal.:________________________Dist.:______________
Land line No.:_________________Mob.:___________________E-mail:______________________________

2) Permenant:___________________________________________________________________________________
Pin: ____________________At_________________Tal.:________________________Dist.:______________
Land line No.:_________________Mob.:___________________E-mail:______________________________

Present Business Activity:

1) _____________________________________________________________________________________________
2)_____________________________________________________________________________________________

1)
2)
3)
4)

Firms Detail:
1) Proprietorship
2) Partnership
3) HUF
4) Pvt. Ltd.
5) Other
Year of Establishment:
Firm VAT Reg. No.:
Firm PAN Reg. No.:
Bank Name with Address:
Account No.:
Annual Turnover:
Present Agro Base Products sale Company details:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Business____________________
Business____________________
Business____________________
Business____________________

 Contact Person details:

1) Name : _________________________________________________________________________________
Residence Address: _______________________________________________________________________
_________________________________________________________________________________
Ph No.: _____________________________ Mobile No.: ______________________________
PAN No.: ____________________________
Ration card/Address proof: ____________________________
Education Qualification:
2) Name : _________________________________________________________________________________
Residence Address: _______________________________________________________________________
_________________________________________________________________________________
Ph No.: _____________________________ Mobile No.: ______________________________
PAN No.: ____________________________
Ration card/Address proof: ____________________________
Education Qualification:
Centre Details:
1) Centre Name:
No. Of Villages:
2) Farmers Financial Position in Area:
Not Good____ Average ______ Good _______ Better _________
3) Irrigation System:
Bore____ Well ______ Canal/Pond _______ Other _________
4) Water Level: _________________ft. Deep
5) Main Crop of Agriculture:
1. ___________________
2. ___________________
3. ___________________
4. ___________________
5. ___________________
6) Rain Falls Days: _____________ Rain Fall inch. (Averg.)_____________
Business Premises details:
1. Location: _____________________
2. Area: _____________________ (Square feet)
3. Front: _____________________
4. Own/Rental: _____________________
Godown Area:
1. Location: _____________________
2. Area: _____________________ (Square feet)
3. Own/Rental: ____________________
Basic Information:
1. Manpower:
2. Technical Staff:
3. Vehicle Details: ______________________________________
______________________________________
______________________________________

FIELD PERSON NAME:_____________________________________________

1)
2)
3)
4)

Reference Details:
Name : __________________________________________________________________________
Address: _______________________________________________________________________ _
Mobile No.: ______________________________
Relationship :

I_________________________________________, here with declare that, Information and

Documents given or attached with this application is right from my side. If any information and
documents are incorrect then I am fully responsible for that matter.

Place:
Date:

Sign. Of Applicants.

FOR OFFICE USE ONLY

Centre Name:
Cheque / DD No.:
Date:
Drown on Bank:
Amount:

Documents Checked by:

Name:
Sign:

Received by:

Dealership Approved By:

Date:

Dist.:

Application Fees Amount: ______________