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REGISTRATION FORM - AGENT
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Mandatory Fields
NAME OF AGENCY :
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Affiliation:
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Year Of Establishment :
TYPE OF COMPANY:
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Partnership
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If partnership specify no.of Partners
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NAME OF PARTNERS / PROPRIETOR :
Address :
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No. of Branches
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Contact Detail :
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Office Landline :
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GSM Number :
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Sponsor's Name :
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Manager Name :
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contact details :
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Mobile Number :
Residence No. :
Email ID: Accounts
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Optional :
Pan Card Holder Name :
Pan Card Number :
GST Number :
Name Of The Bank :
Bank A/C No :
Business Productivity (Monthly) :
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Contact Person :
Number Of Staff :
Residential Address :
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