YOUR FIRM'S DETAILS
FIRM NAME*
Nick Name/Alias (Popularly Known as) – TO BE USED IN LISTING & COLLATERALS*
FIRM'S LEGAL CONSTITUTION*	PROPRIETORSHIPPARTNERSHIPPVT/LTD COCOOPERATIVE SOCIETY/NGOTRUST
COUNTRY	INDIA
STATE*	SELECT ANDAMAN AND NICOBAR ISLANDS ANDHRA PRADESH ARUNACHAL PRADESH ASSAM BIHAR CHANDIGARH CHHATTISGARH DADRA AND NAGAR HAVELI DAMAN AND DIU DELHI GOA GUJARAT HARYANA HIMACHAL PRADESH JAMMU AND KASHMIR JHARKHAND KARNATAKA KERALA LAKSHADWEEP MADHYA PRADESH MAHARASHTRA MANIPUR MEGHALAYA MIZORAM NAGALAND ORISSA PUDUCHERRY PUNJAB RAJASTHAN SIKKIM TAMIL NADU TRIPURA UTTAR PRADESH UTTARAKHAND WEST BENGAL
DISTRICT / BOROUGH*	SELECT if other please specify
REGISTERED OFFICE ADDRESS*
NEARBY LANDMARK*
LOCALITY*
CITY
VILLAGE	TEHSIL / BLOCK
POSTAL CODE*
POSTAL codes NEAR YOU
YOUR  CONTACT  DETAILS
NAME OF AUTHORISED SIGNATORY*	MRMS
DESIGNATION*
MOBILE NO*
DIALLING CODE*	PHONE NO (O)* (R)
FAX	WEB SITE
EMAIL*
DETAIL OF MOBILE PHONE NUMBER TO BE USED FOR BEAM
MOBILE NO
YOUR  PRESENT BUSINESS
Tick [ü] any of the following.
Cigarette / Matchbox / Tobacco ShopMilk-Bread-ButterBranded Fast Food Outlet (specify)Unstarred Hotel/Motel General Merchant / Kirana ShopLadies Hosiery / CosmeticsRestaurantPub / Bar / Lounge Mobile Prepaid Card RetailerSupermarketStarred HotelBooks / Music / CD / Stationery Chemist ShopIndian Fast Food (Halwai) ShopDhaba (Roadside Restaurant)Liquor shop Bakery /Confectionery Other Specify
YOUR  POINT OF SALE'S LOCATION DETAILS
Tick here if address is same as only
ADDRESS*
NEARBY LANDMARK*
LOCALITY*
CITY
VILLAGE	TEHSIL / BLOCK
STATE*	SELECT ANDAMAN AND NICOBAR ISLANDS ANDHRA PRADESH ARUNACHAL PRADESH ASSAM BIHAR CHANDIGARH CHHATTISGARH DADRA AND NAGAR HAVELI DAMAN AND DIU DELHI GOA GUJARAT HARYANA HIMACHAL PRADESH JAMMU AND KASHMIR JHARKHAND KARNATAKA KERALA LAKSHADWEEP MADHYA PRADESH MAHARASHTRA MANIPUR MEGHALAYA MIZORAM NAGALAND ORISSA PUDUCHERRY PUNJAB RAJASTHAN SIKKIM TAMIL NADU TRIPURA UTTAR PRADESH UTTARAKHAND WEST BENGAL
DISTRICT / BOROUGH*	SELECT if other please specify
POSTAL CODE*