REGISTRATION FORM

To be filled by Retailer Service Point (RSP) requesting for B2B Web Service

through PSP – Payworld (Payworld Webpos)

[Soft Copy]

* Mandatory

Company Name *

Person Representing Company

First Name *

Middle Name

Last Name *

Date Of Birth *

Residence Address *

Office Address *

City *
State *

Pincode *(to be verified by the Principal

Agent
Country* INDIA

Phone Number*/Mobile No

Fax Number

Email Id *

Verified PAN No.

Declaration of Sub agent obtained (Soft copy available with the Principal Agent).

Willing to be registered with M/s SUGAL YES

AND DAMANI
He is not registered with any other Principal YES/NO
Agent
SIGNATURE
(Competent authority of Principal Agent)

Name : ( Competent Authority)

Seal of the Company