GET THE MORE ONLINE SHOPPING PHOTOGRAPH OF THE

APPLICANT IN CASE OF
NETWORK PROPRIETARY AND HUF
A.B. ROAD, NEAR OLD PALASIA,
OTHERWISE SEAL OF
INDORE (M.P.) THE FIRM/COMPANY

1. Name of the applicant (in block letters)*

First Name

Last Name

2. Name of the applicant father (in block letters)*

First Name

Last Name

3. Name of the firm (with which name applicant wants to work)*

(A) Registration Number/ROC __________________________________________________________________

(Not applicable to individuals and HUFs. Mandatory for company Company should mention registration number issued by the
Register of Companies. Other applicant may mention registration number issued by any State of Central Government Authority)

(B) Local Sale Tax No. (TIN No.)* ________________________________________________________________

4. Fathers Name (applicable in case of Proprietor firm)*

First Name Middle Name

Last Name

5. Telephone Number*

6. Mobile Number*

+91
+91 7. E-Mail ID : (in block letters)*

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8. Date of Birth / Incorporation / Agreement / Partnership of trust Deed / Formation of Body of Individuals /
Association of Persons* ____/____/_______ (DD/MM/YY)

9. Address:

(A) Residential Address

Flat/Door/Block No.

Name of the Premises/Building/Village

Road/Street/Lane/Post Office

Area/Locality/Taluka/Sub-Division

Town/City/District

(B) Official Address

Name of the office

Flat/Door/Block No.

Name of the Premises/Building/Village

Road/Street/Lane/Post Office

Area/Locality/Taluka/Sub-Division

Town/City/District

10. Worked Experience: (If works/working with any other Teleshopping Company)

Name of the Companies:

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 Working From

Geographical Area :

Name of the Companies:-

Working From
Geographical Area :
Name of the Companies:-

Working From
Geographical Area :
Name of the Companies:-

Working From
Geographical Area :

11.Area Mapping*

Area name8
Dealers Delivery
Point

Area name 1 Area name 2 Area name 3 Area name 4

Area name 5 Area name 6 Area name 7

(Please fill the distance in kilometers between two points, mention as arrows)

12. Bank Account Details:*

Account Holders Name:

Bank Name:

Account No. :

Type of Account:

Saving Current

Branch Code:

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MICR Code:

NEFT/RTGS Code:

13.Declaration:*

I ____________________________________________ do hereby solemnly affirm that the particulars and

information given above are true and correct to the best of my knowledge and belief and no part of it is false and that
I have not with-held or concealed any fact of information. In case any part of the information given above is found
to be false or incorrect, my dealership is liable to be terminated without notice. And I promise to follow all the rule
and regulation draft and signed by me in the contact between me and company under the Indian Contract Act 1872.

14.Identity Proof:*

(Copy of any of the following: PAN Card/Depository Account Statement/Bank Account Statement/Bank Pass Book/Rent
Receipt/Passport/Voters Identity-Card/Driving License/Certificate of identity signed of Parliament or Member of Legislative
Assembly or Municipal Councilor or Gazetted Officer.)

15.Address Proof:*

(Copy of any of the following: Electricity Bill/Telephone Bill/Depository Account Statement/Bank Account Statement/Bank Pass
Book/Rent Receipt/Passport/Voters Identity-Card/Property Tax Assessment Order/Driving License/Certificate of address signed
by Member of Parliament or Member of Legislative Assembly or Municipal Councilor or gazette Officer.)

Date:

Place:

Recommended by:

Signature (Applicant)*

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