FORM

1 Registered Business Name of

Applicant ( in Block Letters)
2 Registered Address
(in Block Letters)

3 Delivery Address

Billing Address

CIVIL LINE, BEHIND TELEPHONE EXCHANGE,

NEAR HANUMAN MANDIR,
GONDIA
State :
PinCode:
4 Type of Business Entity ( Pl.Tick)

State :

PinCode :
Sole Proprietorship
Partnership
Pvt Limited Co
Public Ltd Co

5 Central Sales Tax No & Date

6 Local Sales Tax No & Date
7 Tin No & Date
8 Income Tax Pan No
9 Date of Commencement
10 Telephone Nos
Fax Nos
E Mail ID
Cell Phone No
11 Full Details of

Name

Proprietor

Partners

Home Address &

Telephone Nos

Directors
Qualific
ations

Ownership %

Contd .. 2

:2:
10 Contact Names

Phone Nos

Accountant
Director
Puchasing Officer
Sales Manager
11 Organisation Structure : ( Organisation chart may be enclosed)
No.of Employees :

Management Staff :

12 Description of Business :

13 Bank Name & Address

Name
AXIS BANK
A/C No
913020034512097
Credit Limits (if any)
The applicants undertakes to provide advance
intimation to MIL before closure of any Bank a/c
from which cheques have been issued

14 This is to authorise MIL to verify our

Phone No & Contact Person

Bank / Trade Credentials

Name & Signature of Authorised Signatory

with Official Seal

Applicants's Signature attests financial responsibility

Name :

to pay MIL's invoices in accordance with the agreed

upon terms

Designation :
Signature :
Official Seal :

Fax Nos