DEALER REGISTRATION FORM

FCL - SWITCH & SWITCHGEAR DIVISION DEALER CODE

BRANCH _________________ TO BE FILLED UP BY HO

(PLEASE FILL UP THE DATA IN CAPITAL LETTERS ONLY)

1 CONTACT DETAILS :

SHOP / FIRM NAME

PROPRIETOR
ADDRESS
TOWN / CITY L/L TELEPHONE NO. STD -
DISTRICT MOBILE NO.
STATE EMAIL ID
PIN GST NO.
DATE OF BIRTH (OWNER)

2 BANK DETAILS :

BANK IFSC CODE

BRANCH PAN NO.
ACCOUNT NO. (PLEASE ATATCHED CANCELLED CHEQUE OF THE FIRM)

3 BUSINESS DETAILS : ANNUAL TURNOVER (IN Lacs) :

4 PRODUCTS / BRANDS DEALING :

OTHER SWITCH /
FINOLEX PRODUCTS - (Tick) AVERAGE RETAIL SALES/MONTH-
SWITCHGEAR BRANDS
LDC
FANS
WATER HEATERS
LIGHTING

5 DOCUMENTS ATTACHED :

(Tick) (Tick) (Tick) (Tick)

AADHAR / VOTER CARD PAN CARD VISITING CARD CANCELLED CHEQUE

6 DEALER SIGN & DATE DEALER STAMP

7 VERIFIED BY :

SALES EMPLOYEE NAME EMP CODE SIGNATURE PM/ BH SIGNATURE