Sampark

NEW REGISTRATION FORM

BUSINESS
RDDM
PHYSICAL VERIFICATION
DELIVERY ADDRESS

SapCode:

MOBILE NO*

PLEASE ENTER AT LEAST 10 DIGIT MOBILE NO PLEASE ENTER MOBILE NO

OTP SENT SUCCESSFULLY

FIRM NAME

PLEASE ENTER FIRM NAME FIRM NAME CAN NOT BE CHANGED AS BANK DETAILS APPROVED

USER TYPE

UserSubType

Please Select Sub UserType

USER STATUS

REMARK:

HAVELLS ID

ELECTRICIAN 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

CURRENT ADDRESS*

PLEASE ENTER CURRENT ADDRESS

PIN CODE*

PIN CODE *

AREA *

PLEASE SELECT AREA

CITY *

PLEASE SELECT CITY

DISTRICT*

PLEASE SELECT DISTRICT

STATE *

PLEASE SELECT STATE

BRANCH NAME *

REGION NAME

SALES OFFICE NAME *

PLEASE ENTER SALES OFFICE NAME

PERMANENT ADDRESS

PLEASE ENTER PERMANENT ADDRESS

DOB*

DOB SHOULD BE 18 YEARS OR ABOVE

EMAIL*

PLEASE ENTER EMAIL PLEASE ENTER VALID EMAIL

DRIVING LICENCE*

PLEASE ENTER DRIVING LIECENSE NO PLEASE UPLOAD DRIVING LIECENSE & PICTURE

VOTER ID*

PLEASE ENTER VOTER ID PLEASE UPLOAD VOTER ID & PICTURE

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 ATLEAST ONE ID PROOF

GST TYPE

PLEASE SELECT GST OPTION

GST No*

PLEASE ENTER GST NO PLEASE ENTER VALID GST NO PLEASE ENTER PAN NO OR GST NO

DRIVING LICENCE IMAGE(FRONT)

PLEASE SELECT DRIVING LICENCE FRONT IMAGE

DRIVING LICENCE IMAGE(BACK)

PLEASE SELECT DRIVING LICENCE BACK IMAGE

VOTER ID IMAGE(FRONT)

PLEASE SELECT VOTER ID FRONT IMAGE

VOTER ID IMAGE(BACK)

PLEASE SELECT VOTER ID BACK IMAGE

AADHAR IMAGE(FRONT)

PLEASE SELECT AADHAR FRONT IMAGE

AADHAR IMAGE(BACK)

PLEASE SELECT AADHAR BACK IMAGE

PAN IMAGE

PLEASE SELECT PAN IMAGE PLEASE UPLOAD PAN NO & PICTURE

SHOP IMAGE

OTHER IMAGE

TCS ELIGIBILITY

Please Select TCS Eligibility

TDS ELIGIBILITY

Please Select TDS Eligibility

NOMINEE INSURANCE DETAILS

INSURANCE STATUS

POLICY NO

PERIOD OF INSURANCE

NOMINEE NAME*

NOMINEE RELATION*

NOMINEE DOB*

DOB SHOULD BE 18 YEARS OR ABOVE

BANK ACCOUNT NO

IFSC CODE

BANK NAME

BANK ADDRESS

NAME ON CHEQUE

IDENTITY PROOF IMAGE(FRONT)

OWNER IMAGE

BANK DETAILS

BANK STATUS

BANK ACCOUNT NO.*

IFSC CODE*

BANK NAME

BANK ADDRESS

NAME(AS IN BANK AC)*

TERMS & CONDITIONS

Insurance is the subject matter of the solicitation. I understand the Terms & conditions associated with the policy & Havells in no way is responsible in case of any discrepancy found in the future.

Physical Verified EmployeeId*