APPLICATION FOR APPOINTMENT AS AUTHORISED CEMENT DEALER ACC LIMITED

Ref: ACC/SURPR/ACD.

1. Place (S) where dealership is required – Town _______________________________.

Tehsil__________________________ District______________________________.

2. Name in Full Mr. / Mrs / MS. _____________________________________________.

3. Full Postal Address:
(a) Shop _________________________________________________.

_________________________________________________.

(b). Godown _________________________________________________.

_________________________________________________.

(c ). Residence _________________________________________________.

_________________________________________________.

4. Telephone No. STD Code : ______ - ________________. Mob No._______________.

5. (a) Is your firm:

Proprietorship / Partnership / Joint Hindu Family.

(b). Mention the name(s) of the proprietor / partner / karta :

Name Percentage Share (%).

________________________________ _________________

________________________________ _________________

________________________________ _________________

________________________________ _________________

(if partnership / JT. Hindu Family Firm, Please send true copy of the partnership deed.)

6. How long have you been established in the place where dealership of desired : _________ Years.
(Please enclose nativity certificate)
7. (a). Are you our dealer at any other place ? (Yes) (No)
(Appointment letter may be enclosed)
 (b). Have you made any previous application ? (Yes) (No)

(if so, please send a copy of our reply to you).

8. What is the approximate consumption of cement per month in your tow ?

Total: ____________ MT. / Month.
Brand : _______________ ______________ ______________ ________________ ____________.

9. How much cement business do you guarantee per month : _______________MT.

10. Are your or anyone connected with you in the building contracts Business : (Yes) (No).

Details : ___________________________________________________________________________.

11. Have you any contacts with Revenue Authority, Govt. Official, Prominent Businessmen etc: (Yes) (No).

Please give their full name designation and address in case we wish to make any reference.

12. Have you at any time handled our (ACC) Cement directly or as a dealer with any of our dealers: (Yes)
(No)

Details : __________________________________________________________________________.

Or have you handled or presently handling any other brand of cement : (Yes) (No).

Details: ___________________________________________________________________________.
13. Your present business. Give particulars of the firm or industry you represent.
Year Estd. Business Current Yr . Sale (Rs.) Last Yr. Sale (Rs.)

14. Any other Information you may like to give in support of your request:

CREDIT APPRAISAL

15. How much money can you set apart Exclusively for cement business per month : Rs. ________________.

16. (a) Is your house owned by you or rented : (Owned) (Rented)

 (Please enclose photo copy of ownership papers.)

Details : _____________________________________________________________________________.

(b) Is your godown owned by you or rented : (Owned) (Rented)

(Please enclose photo copy of ownership papers.)

Details : _____________________________________________________________________________.

(c) Is your shop owned by you or rented : (Owned) (Rented)

(Please enclose photo copy of ownership papers.)

Details : ____________________________________________________________________________.

17. Kindly enclose your last 3 years audited balance sheet and give details: Enclosed / Not Enclosed.
18. Name & Address of your bankers:
___________________________________________________________.
(Please enclose introduction letter from them.)
19. Details of liabilities including loans as on.
1.____________________________________________________________________________________.

2.____________________________________________________________________________________.

3.____________________________________________________________________________________.

20. Are your purchasing cement on credit ? if yes, mention no. of days of credit availed and sources thereof. :

21. Are you in a position to give any security for the credit: (Yes) (No)

Particulars of Security Market Value (Rs.)

Bank Guarantee : ________________________________________________________________.

Others :_________________________________________________________________.

: _________________________________________________________________.

Is there any other charges on the Security ?: (Yes) (No)

If yes , to what extent ? ____________________________________________________________.

22. Credit facility desired from ACC :

(1). No of Days : ___________________________.

(2). Amount not exceeding Rs. : ___________________________.

(3). Security to ACC : ___________________________.

23. REFERENCE :

Name & Address of two Referees:

(1). ________________________________ Address : ___________________________________.

 (2). ________________________________ Address: ___________________________________.

24. Enclosures : Enclosed

(1). Audited copies of Profit & Loss Account and Balance Sheet for Last (Yes) (No)

Three Years.

(2). Latest Income Tax Clearance Certificate. (Yes) (No).

(3). Photocopy of Sales Tax Certificate (Yes) (No).

TIN No. _______________________________. PAN No. ________________________________.

(4). Partnership Deed. (Yes) (No)

(5). Nativity Certificate. (Yes) (No)

(6). Ownership Paper :

(a). House : (Yes) (No)

(b). Residence : (Yes) (No)

(c.). Godown : (Yes) (No)

(d). Shop : (Yes) (No)

(7). Introduction letter from your banker. (Yes) (No)

25. Declaration:

We declare that all the particulars and information given in this form are true and complete. We
further confirm that there has been no insolvency proceedings against us/ our partners/directors. We agree to
abide with the terms and conditions of ACC as decided from time to time.

Signature________________________________.

Partner / Director/ Proprietor

Rubber Stamp.

PLACE : ____________________________

DATE :____________________________.