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Declaration Form PDF

This document is a customer application form that collects information from potential customers. It requests: 1) Customer contact and address details, as well as whether they are a dealer, distributor, or direct customer. 2) Bank account information including account number, IFSC codes, and a blank cancelled cheque. 3) Details on security deposits or advances. 4) Primary contact information including names, phone numbers, and email. 5) Registration details like PAN, TAN, and GSTIN numbers along with supporting documents. The applicant declares the information is correct and won't hold the company responsible for delays or failures in transactions due to incomplete information.

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Boopathi Kalai
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813 views2 pages

Declaration Form PDF

This document is a customer application form that collects information from potential customers. It requests: 1) Customer contact and address details, as well as whether they are a dealer, distributor, or direct customer. 2) Bank account information including account number, IFSC codes, and a blank cancelled cheque. 3) Details on security deposits or advances. 4) Primary contact information including names, phone numbers, and email. 5) Registration details like PAN, TAN, and GSTIN numbers along with supporting documents. The applicant declares the information is correct and won't hold the company responsible for delays or failures in transactions due to incomplete information.

Uploaded by

Boopathi Kalai
Copyright
© © All Rights Reserved
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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CUSTOMER APPLICATION FORM

1. Name and Addressdetails:


Customer Name (As registered in your bank)

Customer Type Dealer/Distributor Direct Customer Govt Customer


Status(Proprietorship/Firm/Company)

Registered Office Address

State : Pin Code :

Communication Address

State : Pin Code :


Shipping Address

State : Pin Code :


Invoice Should be in the Name of
(Please attach a self-attested copy of Partnership deed/Memorandum and Article of Association, as applicable)
2. Particulars of your Bank account:
Name of the Bank Account holder/s
Name
Address of the Telephone & Fax of the
Branch Branch
Bank Account 9-digit MICR code
number no.
IFSC– NEFT IFSC – RTGS (Real
(National Electronic Time Gross
Fund Transfer) Settlement)
SWIFT code Account Type:
Saving/Current
(Please attached a blank cancelled cheque of the above stated bank, for verification of the above bank particulars)

3. Security Deposit / Advance details:

4. Your contact details:


Contact Person/s
Telephone & Mobile No
Email Address which is authorized to receive
payment details/communications from us/our bank
5. Registrations related details:
PAN (PAN self-attested Copy Compulsory to beprovided)
TAN No.
GSTIN No.
I/We hereby declare that the particulars given above are correct and complete in all respects. If the transaction
is delayed or not effected at all for any reason (including due to incomplete or incorrect information provided
by me/us), I/We will not hold FUJIFILM India Pvt. Ltd. (FFIN) responsible for any loss caused to me/us.
Further, I/We also understand that FFIN shall not be held liable for any irregularities (whether procedural or
otherwise) of the payer’s or payee’s banks. And that I am expected to follow all rules, regulations and
procedures set forth by FFIN and such banks in this regard.
(Signature of Authorized Person)
Name Designation

(With Business Seal in case of Company/ Partnership Firm/Sole Proprietorship)

FOR FFIN USE: Division: Customer Code No. allotted SAP Code No.
Documents received □ Copy of Partnership deed/MOA & AOA □ Blank cheque □ Copy of PAN
Security Deposit Details/Remarks

FFIN Representative Name, Designation & Signature


TO WHOM SO EVER IT MAY CONCERN

This is to certify that, we (Lab/Studio Name & Address……………………………


……………………………………………………………………………………………………………
…………………………………………………………..) declare that our firm does not have any
GSTIN registration as we are not registered under GST.

We are not having TAN number also

Please update us in your records as unregistered Customer. We know that we cannot claim
any input benefit as unregistered Customer.

For……………………………………….

Authorized Signatory

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