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Customer Registration Form: Fields Marked Are Compulsory

This document is a customer registration form for Jodhpur Healthcare Pvt Ltd. It provides their registered address in Jodhpur, Rajasthan, India as well as contact information for Mr. KHS Shekhawat. The shipping address is the same as the registered address. The billing address is also listed as the registered address. The customer declares that the information provided is true and correct.

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gajendrabanshiwal8905
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65 views

Customer Registration Form: Fields Marked Are Compulsory

This document is a customer registration form for Jodhpur Healthcare Pvt Ltd. It provides their registered address in Jodhpur, Rajasthan, India as well as contact information for Mr. KHS Shekhawat. The shipping address is the same as the registered address. The billing address is also listed as the registered address. The customer declares that the information provided is true and correct.

Uploaded by

gajendrabanshiwal8905
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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CUSTOMER REGISTRATION FORM

Customer Name (Legal Name)* Jodhpur Healthcare Pvt Ltd


Registered Address* Jodhpur Healthcare Pvt Ltd
E-4,MIA,Basni 2nd Phase,Jodhpur
Rajasthan

City Jodhpur Zip Code 3 4 2 0 0 5


State Rajasthan Country India
PAN of the Customer* AACCJ9336P
Contact Person* Mr.KHS Shekhawat Phone* 0291-2723486

Email Id* [email protected]' Mobile* 9893114572

SHIPPING ADDRESS
Type of Project* o New Installation / MOD o Maintenance o Repair / Supply of Spare
Project Name* Jodhpur Healthcare Pvt Ltd
Shipping Address* Jodhpur Healthcare Pvt Ltd
E-4,MIA,Basni 2nd Phase,Jodhpur
Rajasthan

City Jodhpur Zip Code 3 4 2 0 0 5


State Rajasthan Country India
Service Tax No. VAT TIN
TAN (Income Tax) TAN (WCT)
CST No.
Contact Person* Mr.KHS Shekhawat Phone* 0291-2723486

Email Id* [email protected]' Mobile* 9893114572

BILLING ADDRESS* o Registered Address o Shipping Address o Any Other(Pls Specify Below)
Customer Name Jodhpur Healthcare Pvt Ltd
Billing Address Jodhpur Healthcare Pvt Ltd
E-4,MIA,Basni 2nd Phase,Jodhpur
Rajasthan

City Jodhpur Zip Code 3 4 2 0 0 5


State Rajasthan Country India

Information in case of E1 transaction


Consignee/ End user
Consignee's address

VAT TIN CST No.

City Zip Code


State Country

DECLARATION

I/We hereby declare that the above information is true and correct to the best of my/our knowledge

Customer's Signature & Stamp


Name :
Designation :

For ThyssenKrupp Elevator (India)

Project Name Jodhpur Healthcare Pvt Ltd


Job No.
CUID

Name Utkarsh Kansoria


Designation Executive-Sales
Department NI-Sales
Date 9/12/2013 Signature

Fields Marked * are compulsory

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