Dealer/ Distributor Appointment Form

Karnataka Agro Chemicals Multiplex Agricare Pvt. Ltd. Multiplex Fertilizers Pvt. Ltd.
Branch Location:
Recent
H. Q. / Territory Name: Passport
Photograph
Date: ………../……….../ 20…………

Name of the Firm

Constitution   Proprietorship   Partnership   Pvt. Ltd.   Others

Type of Sale   Wholesale  Retail

  Both

Complete Address

Taluk: District:

State: Pin code:

Contact Number 
E-Mail ID:
Proprietor / Partners Name

PARTICULARS
1.Current Annual
Turnover 2. Operating 3. Number 4. Any Other Fertilizer/Micronutrient Company Distribution is
Since: of Employees : there or not?  YES  NO If yes details:
Rs. …………………. ……………..Years ………… ………………………………………………………………………………
(in Lakhs)
5.Split Turnover Fertilizers: Pesticides: Seeds: Micronutrients:
(in Lakhs)
Annual
SL Operating Payment
Name of the Companies Major Products Turnover
No. Since Policy
(Lakhs)
6. Presently
Associated 1
With: 2
3
4
5
7. Godown 8. Additional Branches (If any)  YES  NO 9. Shop / Office
Space: 10. If Wholesaler
Locations……………………………………………………………………….  Own No. of Retailers Covering

…………………….
……………………………………………………………………………………….
 Rented …………………………………
(in Sq Ft)
11.Recommended Transporter (2 Options) : 1) 2)

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 12.Registration Details: 13.SECURTIY DETAILS: “No interest on security deposit”
GST Number: * Dealer/Distributor Bank Account statement compulsory for Electronic Mode Transfer.
Karnataka Agro Chemicals Multiplex Agricare Pvt. Ltd.
_____________________________
License Number : Security Amt Rs. Security Amt Rs.

_____________________________  Cheque  Electronic Mode  Cheque  Electronic Mode

PAN Number: :
______________________________ Cheque No./E-Mode Transfer No. Cheque No./E-Mode Transfer No.

Expected Business/Year :
Cheque Date/E-Mode Transfer Cheque Date/E-Mode Transfer
Rs._______(Lakhs) Date: Date:
Bank Name: Bank Name:
Credit Limit Proposed:
Rs._______(Lakhs) Clearing Date: Clearing Date:

Clearing Bank & A/c No. Clearing Bank & A/c No.
Credit Period Proposed _______(in Days)
Focused Crops:
Blank Cheques Offered :  YES  NO
Reason/ Justifications for (Minimum 2 CTS Cheques)
Appointment : Bank Name Account Number Cheque No. Company

Referred By: ____________________(Area In charge) Recommended By: __________________(Sales Head)

Verified By: ____________________(Branch Manager) Approved By: _______________________( HO: MCO/ MD)

Customer Code: Security Code: Credit Limit Approved: Rs._____________(in Lakhs)

Terms & Conditions :

a) PRICE: As per company price list and subject to revision from time to time. All stated prices are exclusive of any taxes and as applicable will be extra.

b) MODE OF PAYMENT: WE ACCEPT PAYMENT ONLY IN ELECTRONIC MODE (i.e. RTGS/ NEFT/ IMPS etc.).

c) JURISDICTION: Bangalore, Karnataka d) SALES RETURN: Within 15 Days from the date of receipt if any Leakage, Damage received and Expired Goods will

not be taken back. e) TRASNPORTATION: Till your premises will be paid by company and secondary freight will not be allowed.

f) TERMINATION: By 30 days’ notice in writing on either side with settlement of accounts. g) OTHERS: As per company price List.

I/We, d I/We hereby declare that all the particulars given in this application are true and complete and that I/We, had no insolvency proceedings. I/We, agree that you
may take up such reference and make inquired as you may deem fit. I/We, also affirm that the annexures to this applications are the correct copies of their originals.
I/We hereby declare that will abide by the company rules, regulations, policies and Terms and conditions of this agreement as long as I/we, Continue to deal with the
company. I/We agreed that NO CASH payment or STOCK will be given to any company’s employee for any reason if so, we take full responsibilities and will make
your payment in time.

…………………………………………………. Name: Place:

(Dealer/Distributor Signature with Stamp and Date)

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