DEALERSHIP APPLICATION FORM

(Please fill up in block letters only)

FOR OFFICE USE ONLY

Application Form No:…...................

Code :............................................. Affix passport size

photograph and
sign across

1. Name of proprietor:.............................................................................................................

2. Name of the Firm :..............................................................................................................

3. Mailing address:...........................................................................................................................................................

..........................................................................................................................................................................................

..........................................................................................................................................................................................

4. Phone No. (with STD code) :........................................................................................................................................

Mobile No.(s) :..............................................................................................................................................................

E-mail :.........................................................................................................................................................................

5. Details of Bank A/c. :

a) Name and address of Bank :.................................................................................................................................

b) Type of A/c. (tick ) : Savings Current Other (Please specify):...................................................

c) Account No. :...........................................................IFSC Code..........................................................................

d) Name of Authorised Signatory :...........................................................................................................................

(attach last six month's Bank Statement)

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5. Name of firm/company under which dealership will exist :........................................................................................

6. Status of firm (tick ) : Proprietorship Partnership LLP Limited / Private Ltd. Co.

(Partnership firms enclose copy of partnership Deed/ For LLP, deed of LLP, for Companies Memorandum Articles of
Association)

7. Details of Proprietor/Partners/Directors:

Date of Pan No.

Sl. Name Birth Father’s/Husband’s Name
(dd/mm/yy)
1.

2.

3.

4.

8. Name and address of associate firm(s): ......................................................................................................................

9. Turnover : ....................................................................................................................................................................

10. Details of Security Deposit:

DD/Cheque No.:..................................................................................................................................................

Date:......../......../.............. Amount (in Numbers):............................................................................................

Bank: ...................................................................................................................................................................

Payable at :..........................................................................................................................................................

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11. Your current business (tick  )

a) Cement b) Hardware c) Paint d) No business

e) Other (please specify) :..................................................................................................................................

12. Last three years turnover of your firm (Amount in lacs)

(I)..................................................... (ii)........................................................
(iii)...........................................................

13. Please indicate how much you wish to increase turnover with this dealership (*Rs. lacs):
........................................

14. Are you on Income Tax payer ? (tick ) : Yes No.

Income Tax Permanent A/c Number (PAN/GR No.)

(Attach copies of income Tax Return for last three years)

15. Are you a registered dealer? Yes No

(a) MVAT / TIN No : ..................................................................................................................................

(b) CST / TIN No : .............................................................................................................................................

16. Indicate number of persons employed in your firm (including active partners) ........................................................

17. (a) If you are dealing cement specify since when have you been in the cement/wall putty/plaster trade.

Since Specify the brands you deal in now................................................................................................................

.................................................................................................................................................................................

(b) If you have discontinued dealing in any brand(s) of cement/wall putty/plaster please specify the
reasons there to.
..................................................................................................................................................

.................................................................................................................................................................................

18. (a) Do you have warehousing facility? Yes No

(b) Indicate size and capacity of warehouse (Tone/Sq.ft.): ......................................................................................

(c) Address of warehouse: ........................................................................................................................................

Attach copy of Trade License

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19. (a) Details of where dealership being applied for :

Town: ......................................................................................................................................................................

A/P : ........................................................................................................................................................................

District:....................................................................................................................................................................

State : ........................................................................................................ Pin Code: ............................................

(b) Where Municipal Corporation/Panchayat :..............................................................................................................

(c) Nearest wall putty/plaster dealer’s Name :..............................................................................................................

Distance:..................................................................................................................................................................

(d) Monthly consumption of total wall putty/gypsum plaster of all brands in your town/city :……………………………

(e) Brand-wise details:

BRANDS MONTHLY SALES

(f) Expected Minimum sales per month :……………………..........................................................................................

20. (a) Name of wife/husband :........................................................(b) Date of birth of wife/husband:……………………

(d) Number(s) of children :...........................................................................................

21. Name of children(s) : (male,male) Sex(M/F) Date of birth(dd/mm/yy)

(I) ........................................................ .............................. ........./.........../..............

(ii) ........................................................ .............................. ........./........../...............

Place:.................................................. Date:........../........../..................
Signature of the applicant(s)
(with rubber stamp)

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Date: / /

To,

HEALCONS PRIVATE LIMITED

A/p- Vitner Dis – Jalgaon (M.S)

DECLARATION

I/We do hereby declare that the information furnished herein is true & correct to the best of my/our knowledge and
belief. For any incorrect information/false-information furnished herein and for non-compliance of company's policies
formulated, I/We agree that:

1. The Company shall have the absolute right to reject my/our application for appointment as a dealer.

2. The Company shall have the right to forfeit or adjust the whole or part of my/our Security Deposit with
them in the manner they may deem fit.

______________________
Signature of the applicant(s)

(with rubber stamp)

Witness :1............................................................................
.
Full name :...........................................................................

Address :.............................................................................

…………..............................................................................

…………………………………………………………………….

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FOR OFFICE USE ONLY

Comments of sale promoter Agent/Area/ Marketing Manager

Application form No.:.....................................

Dealer Code :.....................................

1. Location of business/premises :

Ideal Suitable Under development Not suitable

2. Warehouse capacity :
(a) Area in sq. feet:.......................................... (b) Capacity in bags:.........................................

(c) Construction: Permanent Temporary

3. Experience and capability : ..........................................................................................................................................

4. Financial standing and capability to invest : ................................................................................................................

5. Market reputation and credibility : Excellent Very good Good Average Poor

6. Business potential of party : (Estimated sales/month)................................... Mt/t /month (Metric ton/ton)

7. Total market potential of the area :.............................................Mt/t /month (Metric ton/ton)

8. Assurance of minimum turnover:............................................Mt/t /month (Metric ton/ton)

9. Banker's reference and rating : (attach banker's letter)

10. Credit rating of party : Excellent Very good Good Average Poor

11. Approximate number of competitors stockist’s in the area/town (major competitors):…………………………………

12. Name of the dealer(s):..........................................................................................................................................

13. Interests and hobbies of the dealer :.........................................................................................................................

14. Special achievement:................................................................................................................................................

15. Credit limit:..................................................................................................................................................................

Remarks (if any)

Signature:.......................................