Sampark

NEW REGISTRATION FORM

BUSINESS
RDDM
PHYSICAL VERIFICATION

SapCode:

FIRM TYPE *

Please Select 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 *

Please Enter Email Please Enter Valid Email

SAP CODE

AADHAR ID

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

GST TYPE

Please Select Gst Option

GST NO

Please Enter GST No Please Enter Valid Gst No

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

Physical Verified EmployeeId*

Please Select Employee

Kam Employee Id*