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Retailer Distributor Form Egpay India

The document appears to be a retailer/distributor requisition form requesting basic information such as name, address, contact details, payment details, and the type of account being applied for whether it be master distributor, distributor, or retailer. Upon approval, it provides allotted identification details and loaded balance amounts. The form collects signatures to declare the information provided is correct and includes contact information for account balance inquiries, refund requests, or technical support.

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4114018
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119 views1 page

Retailer Distributor Form Egpay India

The document appears to be a retailer/distributor requisition form requesting basic information such as name, address, contact details, payment details, and the type of account being applied for whether it be master distributor, distributor, or retailer. Upon approval, it provides allotted identification details and loaded balance amounts. The form collects signatures to declare the information provided is correct and includes contact information for account balance inquiries, refund requests, or technical support.

Uploaded by

4114018
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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L:-+91 11 2258 2258

M:- +91 9650 590 590


E:- [email protected]
W:- www.egpay.in

Retailer/Distributor Requisition Form


Date:Establish/Shop Name:-

..

User Full Name: -

Father/Husband name:-

Date of Birth: -

Working Since:-

PAN Card:-

Other ID Name/No: - ...

Education: -

Up to Metric

High School

......

Sr. Sec. School

Graduate

Post Graduate

Current Mobile No. :-

(This mobile number will be used as user ID for offline/Online)

Other Number: -

Email ID:-

Shop Address:-

..

Pin Code:- .
Residence Address:-

.
Pin Code:- .

Apply For: -

Master Distributor

Amount: Received: Type of Payment: -

Retailers

ID Charges: - ..
Cash

Payment Details: -

Distributor

Cheque

Bank Transfer

Cash at Bank

Allotted IDs: - .....


Load Balance: - ...
Demand Draft/Bankers Cheque

Cheque No/DD/ Ref. No: - .. Bank: - .....


Bank Branch: -

Date: - .....

I.. S/o.. declare that all information provided by me is correct.

Signature with stamp


Office Use Only: -

Agent/DST/MDST ID:-. Created By:-... Date: - .

Receipt: - Client Copy


Egpay India Private Limited has received Rs. as ID charge & Rs... Load balance in Cash/Cheque/DD/Transfer
on dated... Cheque/DD/Ref. No . Branch .. Amt..................

Received By

Name: -

Designation:-

Signature

If you have any query, Please send your all query at [email protected]. Send its scan copy to [email protected] and send its hard copy to egpay India
Pvt. Ltd., 1449/46B, 30 Feet Road, Durgapuri, Shahdara, Delhi- 110093. Ph:- +91 11 2258 2258.
Please Call for:- Balance:- +91 8826 198 822

|| Refund:- +91 8826 198 855 || Technical :- +91 8826 198 198

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