CUSTOMER INFORMATION

FORM

Firm Name M/S

Owner/Proporitor/Partner's Details
Name DOB [dd/mm/yy] Contact Number Email Id
Mr./Mrs./Ms.

Mr./Mrs./Ms.

Mr./Mrs./Ms.

First Contact person at address Mr./Mrs.

Second Contact person at address Mr./Mrs.

I hereby request Asian Paints Limited to share all business SMS updates on my below mentioned mobile number and email ID.
I take the responsibility to keep Asian Paints updated on any change in my Mobile number and Email Ids apart from other contact details.
Mobile Number for all communication
+ 9 1 -
Email Id
Complete Postal Address of my office/Home
Address 1

Address 2

Address 3

Landmark ( If Any )

City

Pincode

City Code - Landline Number - /

City Code - Fax Number - /

Documents Copy Verified & Collected

Photo Identity Proof Driving Pancard Passport UID Others

License

Others ( Please Specify )

Address Proof Ration Card Voters ID Bank Statement Others

Others ( Please Specify )

Declaration
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief.

Date: [DD / MM / YYYY] /

/ Place:
Signature of Customer
Collected/Verified/Forwarded By
Sales Officer Name Mr.

Declaration
I hereby declare that the information submitted by the dealer is verified by Me.
Date: [DD / MM / YYYY] /
Sales Officer Signature
/ Place: