Application Form

SATKAR PARIVAR
PRODUCT/SERVICES PURCHASE FORM
PERSONAL INFORMATION:Title :
Mr
Ms
M/s
Paste here your
First Name : __________________________ Last Name : ___________________________
latest passport
Father’s / Husband’s name : ______________________ Date of Birth : ____ /____ /___________
size photo
CONTACT INFORMATION:Permanent Address:Address : _____________________________________________________________________
____________________________________
City/Town : _________________
City/District : ______________________ State : _______________________ Pin Code : __________________
Correspondence Address :Address : _____________________________________________________________________
____________________________________
City/Town : _________________
City/District : ______________________ State : _______________________ Pin Code : __________________
Mobile No. 1 : _______________________ Mobile No. 2 ________________________
Email Id: ____________________________
PRODUCT INFORMATION:Product Code: ________________ Product Name : ______________________
PAYMENT INFORMATION:Amount Deposited : __________________
Cash :
RT Number : ________________
Cheque/DD No. : ____________________ Dated ___ /___ /_________ Bank Name : ___________________________
NOMINEE INFORMATION:Name _____________________ Relation____________________ Contact No ______________________
In case of minor :Date of Birth : ______ /______ /___________
Guardian Name : _____________________________________
TEAM INFORMATION:TL ID______________TL Name_________________________ *Placement______________________
*From H1 to H10 of your TL ID. If there is no room in the position selected, system will place in nearby position where there is a room
in chronological order
Bank Account Details :Bank Name : ______________________________ Branch : _____________________________
Account Number : __________________________ IFSC Code : ___________________________________
I further declare that I have understood all the terms and conditions of purchasing of the product mentioned above and
fully agree for the same. I am purchasing the product as per my own judgment and without any persuasion of any person
including the Team Leader mentioned above.
Signature : __________________
Name : _____________________
Date ___ /___ /_________
Encl.: 1. ID Proof
2. Address Proof
3. PAN Card
4. Any other document required.
-------------------------------------------------------------------------------------------------------------------------------------------------Company’s Receipt:All details given above have been entered into our system at Sr No_____________ on date ___/____/_________ .
Enclosures Received:1. RT No.
2. PAN Card
3. Address Proof
4. ID Proof
Authorized Signatory