DEALER & DISTIBUTOR REGISTRATION FORM

BUSINESS CONTACT INFORMATION

Name*

Date of Business Commenced*

Company Name*

Type of Business*

Business Role*

Registred Company Address City, State Zip Code*

Phone*

E-Mail*

Turn Over*

Photo*

Password*

Confirm Password *

Security Question*

Your Answer*

BUSINESS AND CREDIT INFORMATION

GST NO.*

GST NO.(Attach Copy)*

PAN NO.*

PAN NO.(Attach Copy)*

SECURITY CHEQUE NO.*

BANK STATEMENT LAST 3 Months (Attach Copy)*

Bank Name*

Account Type*

Account Number*

Confirm Account Number*

PERSONAL INFORMATION FOR DIRECTOR AND PARTNER

Name of Proprietor

Address

PAN NO.

Aadhar NO.

Aadhar no.(Attach copy)

Date of Birth

BUSINESS/TRADE REFERENCES

Company Name

Phone

Address

Fax

City,State,Zip Code

Email*

Aggrement

All Invoices are to be paid 21 days from the date of the invoice.
Claims arising from invocies must be maid within seven working days.
By Submitting this application, you authorised LYQA TECHNO SOLUTIONS PVT. LTD to make inquiries into the banking and business/trade refrences that you have supplied.
We Agree to accept the Credit Limits as sanctioned to us and will abide with your credit policy.
We shall provide security and PDC before each Billings as per LYQA TECHNO SOLUTIONS PVT. LTD policy.
We agree to pay interest on delayed payment @24% P.A. and cheque return charges Rs.500/- per return instrument.

Declaration: I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.

Registration form

DEALER & DISTIBUTOR REGISTRATION FORM