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IN158357 DATE: 21/SEP/2018 21:41:32
ID No.:
REFERRER INFORMATION
Referrer ID: IN787984 Referrer Name: SHIVANI DHAMA
APPLICATION INFORMATION
Title (If Individual) Mr./Mrs./Ms: Business Name (If not individual):
MR. N/A
Surname, Given Name (If Individual): Contact Person (Business Entity):
DHAMA; AKHIL N/A
Mailing Address: Cheque Name (Name on the commission cheque):
60/753 AVADH VIHAR MUZAFFARNAGAR AKHIL DHAMA
MUZAFFARNAGAR UTTAR PRADESH 251002 India
(Vihaan)
Shipping Address: Home Phone No & Mobile No:
60/753 AVADH VIHAR MUZAFFARNAGAR 919675571839; 919675571839
MUZAFFARNAGAR UTTAR PRADESH 251002 India
(Vihaan)
Valid ID Type / ID Number: eMail Address:
PAN Card/ DWDPD1949B AKHILDHAMA112211@GMAIL.COM
Nationality & Date of Birth: Mother's Maiden Name:
INDIA; 12/AUG/2000
Name of Beneficiary/Nominee: Relationship to the Beneficiary/Nominee:
SHIVANI DHAMA Sister
Date of Birth of Beneficiary/Nominee:
24/JUN/1995
1. For business entities, an authorised signatory of the company must sign this Distributor Application Form. Received By: _______________
2. You must be 21 years old and above to become a Distributor.
3. By signing below. you certify and acknowledge that you have read and agreed to be bound by the Policies Received Date: _______________
and Procedures.
4. I agree to adhere to the Know Your Customer ( KYC ) requirements as requested by Vihaan Direct Selling Processed By: _______________
(India) Pvt Ltd.
Processed Date: _______________