Retailer Enquiry Form

1. Name :___________________________________________
2. Telephone : ___________________________________________
3. Address : ___________________________________________
4. Email : ___________________________________________
5. Country : ___________________________________________
6. Region : ___________________________________________
7. City : ___________________________________________
8. Postcode : ___________________________________________
9. Additional details : ___________________________________________
10. Are you interested?
1) Indizel Fuel Stations 3) Indizel Fuel Point
2) Indizel Kiosk 4) Indizel outlet
11. Address where the Indizel retail operations will be set up:
12. Address : ________________________________________________
13. State : ________________________________________________
14. Pincode : ________________________________________________
15. What type of business do you currently own?

16. What is the annual turnover (in Rs.) value from your current business
location where you intend to have Indizel retail operations?

Date : ___________________ Signature_______________