Pri nt Appl icati on

IR APPLICATION FORM

IR ID No.: IN222703 DATE: 17/OCT/2014 02:45:19
REFERRER INFORMATION
Referrer ID: HZ646000 Referrer Name: TAREK GARA
APPLICATION INFORMATION
Title (If Individual) Mr./Mrs./Ms: Business Name (If not individual):
MR. N/A
Surname, Given Name (If Individual): Contact Person (Business Entity):
RAJA; RAJU N/A
Mailing Address: Cheque Name (Name on the commission cheque):
SDFSA HYDERABAD RANGAREDDY ANDHRA PRADESH
500018 India (Vihaan)
RAJU RAJA
Shipping Address: Home Phone No & Mobile No:
SDFSA HYDERABAD RANGAREDDY ANDHRA PRADESH
500018 India (Vihaan)
914030555600; 919290969804
Valid ID Type / ID Number: eMail Address:
Company ID/ 2014148 RRRAJA.RAJU1@GMAIL.COM
Nationality & Date of Birth: Mother's Maiden Name:
INDIA; 26/JUL/1986 ADA
Beneficiary: Relationship to the Beneficiary:
RAJA RAJU Brother
PAN Card: BZJPS1747S
Bank Name: HDFC
Bank Acct. No.:
IFS Code:
PREFERRED PLACEMENT INFORMATION
Direct Preferred Placement IR ID No: Full Name: Preferred Placement:
IN112545 UTKARSH GOEL 003 : Ri ght
TERMS AND CONDITIONS
For business entities, an authorised signatoryof the companymust sign this IR Application Form. 1.
You must be 18 years old and above to become an IndependentRepresentative. 2.
Bysigning below. you certifyand acknowledge that you have read and agreed to be bound bythe Policies
and Procedures.
3.
I agree to adhere to the Know Your Customer ( KYC ) requirements as requested byVihaan Direct
Selling (India) Pvt Ltd.
4.
Received By: _______________
Received Date: _______________
Processed By: _______________
Processed Date:_______________
APPLICANT'S SIGNATURE (Requi red for processi ng) DATE
Vihaan DirectSelling (India) Pvt Ltd
IR APPLICATION FORM https://portal.qnetindia.net/eStore4/receiptapplicationformT4.aspx?key=...
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