Sampark

NEW REGISTRATION FORM

BUSINESS
RDDM
PHYSICAL VERIFICATION
DELIVERY ADDRESS

SapCode:

FIRM TYPE

FIRM NAME *

Please Enter Firm Name Firm Name Can Not be Changed As Bank Details Approved

OWNER NAME *

Firm Name and Full Name should not be same Please Enter Full Name Please Enter Only Alphabets Full Name Can Not be Changed As Bank Details Approved

USER TYPE

UserSubType

Please Select Sub UserType

OWNER MOBILE NO *

Please Enter At Least 10 Digit Mobile No Please Enter Mobile No

OTP SENT SUCCESSFULLY

USER STATUS

Remark:

HAVELLS ID

ADDRESS-1 *

Please Enter ShopAddress1

ADDRESS-2

STATE *

Please Select State

DISTRICT *

Please Select District

CITY *

Please Select City

AREA *

Please Select Area

PIN CODE *

REGION NAME

SALES OFFICE NAME *

Please Enter Sales Office Name

BRANCH NAME *

EMAIL*

Please Enter Email Please Enter Valid Email

AADHAR ID *

PLEASE ENTER AADHAR NO Please Enter Aadhar No Or Pan No Please Enter 12 digit Valid Aadhar No

PAN NO*

Please Enter Pan No Please Enter Aadhar No Or Pan No Please Enter 10 Digit Pan No Please Enter Valid Pan No Pan No Should be Match Gst No From 3 to 12 Digit PLEASE ENTER PAN NO OR GST NO

GST TYPE

Please Select Gst Option

GST NO*

Please Enter GST No Please Enter Valid Gst No PLEASE ENTER PAN NO OR GST NO

TCS ELIGIBILITY

Please Select TCS Eligibility

TDS ELIGIBILITY

Please Select TDS Eligibility

PARENT CHILD STATUS

PARENT MOBILE NO.

Please Enter Parent Mobile No

OWNER IMAGE

AADHAR IMAGE(FRONT)

Please Upload Aadhar No And Aadhar Picture Please Select Aadhar Image

AADHAR IMAGE(BACK)

PAN IMAGE

Please Select Pan Image

GST IMAGE

Please Select Gst Image

SHOP IMAGE

OTHER IMAGE

BANK DETAILS

BANK ACCOUNT NO.*

IFSC CODE*

BANK NAME

BANK ADDRESS*

NAME(AS IN BANK AC)*

Physical Verified EmployeeId*