DEALERS SHIP APPLICATION FORM

FOR
HARTEX TYRES, TUBES & SPARE PARTS
To
M/S. Hartex Rubber Pvt Ltd
Branch _____________________ Date: ____________

Dear Sir

We are interested in the dealership of your products & therefore, request you to please enlist our name with
you as authorized dealer. The required particulars are given below for your information and record.

1) Name and Address of Our Establishment

Firm Name Door No

Street Area

Town/ State Pin

Tel. No Office Tel. No Res.

Fax No Mobile No

E-Mail WebSite

2) TIN No : _________________________________ CST No:____________________________

( Please attach valid copy of VAT / CST registration certificate )

3) Firm Type : [ ] Private Ltd. [ ] Partnership [ ] Proprietary

4) Contact Person.
Name of Director[ ], Partner[ ], proprietor[ ]:________________________________________

Land Line No.:_____________________ Mobile No.:_________________________

5) Year of Establishment : ______________

6) Shop / Showroom / Godown : [ ] Own [ ] Rented, Area of godown :__________ Sft.

7) Annual Turnover for last two years :

8) Present Business Details:

Since Details pertaining to previous Financial Year
Dealership Handled Presently
Annual Annual Annual Spares
( Please Provide Name )
Year Tyres Sales Tubes Sales Any other
Qty Sales Qty turnover(Rs)

9) Have you ever dealt with HARTEX before : Yes / No

a. If Yes when and why did the dealing stopped :

10) Average Monthly Requirement from Hartex (Qty) Tyres_________, Tubes________, Value Rs.________

11) Preferred Transport :

12) Bankers Details

Bank Name A/C Type

Bank Address

12) Interest to Promote Hartex Brand : Yes / No

13) Willing to participate in promotional activities for enhancing Hartex brand visibility : Yes / No

We enclose herewith cash/ cheque / bankdraft no_____________ Dt.___________ for Rs.____________

drawn in favour of M/s Hartex Rubber Pvt. Ltd. payable at________________________ being interest free
dealership deposit amount. Please send us your official stamped receipt.

We have discussed and understood the terms and conditions of your company and the same are acceptable
to us.

Thanking You Yours faithfully,

(Signature with Seal)

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Office Use Only
Dealer Code :

District Code :

Transporter Code :

Sales Person Responsible / EmpCode:_________ Name:_______________________________ Signature

Required / Recommended by Approved by HO

Branch
Credit Days

Credit Limit Rs.

Certification from ABM / BM / AM / RM / AGM / DGM / GM ( Please provide the financial status and
standing of the dealer in the market. )

Approved By
Branch Head AM / RM / AGM / DGM / GM VP – Marketing & Sales