SATKAR PARIVAR PRODUCT/SERVICES PURCHASE FORM PERSONAL INFORMATION:Title : Mr Ms M/s Paste here your First Name : __________________________ Last Name : ___________________________ latest passport Father’s / Husband’s name : ______________________ Date of Birth : ____ /____ /___________ size photo CONTACT INFORMATION:Permanent Address:Address : _____________________________________________________________________ ____________________________________ City/Town : _________________ City/District : ______________________ State : _______________________ Pin Code : __________________ Correspondence Address :Address : _____________________________________________________________________ ____________________________________ City/Town : _________________ City/District : ______________________ State : _______________________ Pin Code : __________________ Mobile No. 1 : _______________________ Mobile No. 2 ________________________ Email Id: ____________________________ PRODUCT INFORMATION:Product Code: ________________ Product Name : ______________________ PAYMENT INFORMATION:Amount Deposited : __________________ Cash : RT Number : ________________ Cheque/DD No. : ____________________ Dated ___ /___ /_________ Bank Name : ___________________________ NOMINEE INFORMATION:Name _____________________ Relation____________________ Contact No ______________________ In case of minor :Date of Birth : ______ /______ /___________ Guardian Name : _____________________________________ TEAM INFORMATION:TL ID______________TL Name_________________________ *Placement______________________ *From H1 to H10 of your TL ID. If there is no room in the position selected, system will place in nearby position where there is a room in chronological order Bank Account Details :Bank Name : ______________________________ Branch : _____________________________ Account Number : __________________________ IFSC Code : ___________________________________ I further declare that I have understood all the terms and conditions of purchasing of the product mentioned above and fully agree for the same. I am purchasing the product as per my own judgment and without any persuasion of any person including the Team Leader mentioned above. Signature : __________________ Name : _____________________ Date ___ /___ /_________ Encl.: 1. ID Proof 2. Address Proof 3. PAN Card 4. Any other document required. -------------------------------------------------------------------------------------------------------------------------------------------------Company’s Receipt:All details given above have been entered into our system at Sr No_____________ on date ___/____/_________ . Enclosures Received:1. RT No. 2. PAN Card 3. Address Proof 4. ID Proof Authorized Signatory