Application Form for TATA 1MG

(FORM TO BE FILLED UP IN CAPITAL LETTERS) Form 1

Application No

(Official Use) Application date - -

1 Applicant Name

2 Location/ Address

3 District

4 State

5 PINCODE

6. Do You Have any Experience of Distribution / Wholesale Distribution / Other Distribution?

Yes …………… No…………`

7
Type of Site of Location Urban Rural
8 Investment
Capital: -
……………………………………………………………………………………………………….
(Mr./Mrs./Ku
mari)
Name
(Mr.)
9.1 Address
District State Pin Code
Tel. No. Mob. No.
Email id PAN No.
If “No” applicant is not eligible If “No” applicant is not eligible

9.2 Gender Male Female

(Tick mark whichever is
applicable)
9.3 Date of Birth Age (Proof to be
submitted as when
DD MM YYYY asked by (FMCG) Years Months Days

9.4 Marital Single Married Widow / Widower Divorcee

status
(Tick mark whichever is
applicable)

Clear thumb impression

Signature: .........................

CIN: U24290DL2016PTC302634

5th Floor Tower – B of The Presidency Building,

46/4 Mehrauli Gurgaon Road, Sector 14, Gurugram, Haryana-122001, India