DIC India Limited
Customer Introduction Form
*** Confidential Information when form is completed***
☐ New Customer ☐ Modify Existing Customer
☐ Sold-To Party/ Bill-To Party/ Payer ☐ Ship-To Party
(Please tick one applicable option above, for ship-to Party, only fill in Section A)
Application Date 20/6/2019 [dd-mm-yyyy]
Applicant Name Nishant Birla
Section A - General
Customer A/C No. 0354002100255131 For modification only
Sales Representative Nikhil Khandekar
Company Reg. No. In Case of Companies
GST Reg. No. 27AABCJ1512C1Z9 Please attach Copy
PAN No. AABCJ1512C Please attach Copy
Trading Name SHRI RADHA MADHAV PACKAGING
Registered Name JANKI LEASING & FINANCE PVT LTD Leave blank if same as trading name
Type of Entity Private Limited Company
*please attach your business registration documents to this application
32,SAI INDUSTRIAL ESTATE,MIDC HINGANA,OPP
Business Address CANDICO FACTORY, GUATAM NAGAR,NAGPUR
MHAHARASTRA 440016
32,SAI INDUSTRIAL ESTATE,MIDC HINGANA,OPP
CANDICO FACTORY, GUATAM NAGAR,NAGPUR
Billing Address MHAHARASTRA 440016MIDC,B26/3,RUKHMINI
FLEXIPACK PRIVATE LIMITED,MIDC
KALMESHWAR,NAGPUR,MAHARASHTRA-400001
32,SAI INDUSTRIAL ESTATE,MIDC HINGANA,OPP
CANDICO FACTORY, GUATAM NAGAR,NAGPUR
Delivery Address MHAHARASTRA 440016MIDC,B26/3,RUKHMINI
FLEXIPACK PRIVATE LIMITED,MIDC
KALMESHWAR,NAGPUR,MAHARASHTRA-400001
Postal Code 440016 Phone 9373289439
City NAGPUR Fax
Business Start Date Click or tap to enter a date.
Section B - Financials
Financial year ended 31/3/2020 [dd-mmm-yy] for below mentioned financial data
Total borrowings
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DIC India Limited Customer Introduction Form
*** Confidential Information when form is completed***
Total accounts payable
Share capital
Revenue
Cost of sales
*please attach your most recent financial statements to this application
Has the business ever been declared insolvent, had an administrator appointed or entered into
any arrangement for the benefit of creditors?
No. If yes, provide details here.
Section C - Directors/Partners/Owners
Ever declared
Name Residential Address
bankrupt?
1 NISHANT BIRLA AMBAZARI NAGPUR No
2 Choose an item.
3 Choose an item.
Section D - Business references
Business name and address Contact person Phone Email
1
2
*please provide at least 2 references
Section E - Sales activities
Product Division PRINTING INK e.g. Printing Ink, Pigment, Polymers and etc…
DIC Current Share % 50% In Case DIC does not having any share. Pl attach
Profitability Statement with estimated sales.
Supplier Name Supplying Percentage
Major Supplier 1 Share DIC 50
Major Supplier 2 Share VANKATESH INK 50
Please provide a brief of customer’s business activities – products, scale of operation (eg. size of
plant, type of production machinery) and any other information relevant to this credit application.
ALREADY EXSITING CUSTOMER, REINTRODUCTION
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DIC India Limited Customer Introduction Form
*** Confidential Information when form is completed***
Section F - Details of Customer’s Accounts Payable function
Name of contact person NISHANT BIRLA
Position held DIRECTOR
Email address nishantbirla@hotmail.com
Phone 9373289439
Communication preference for statement of accounts Email
Email address or Fax nishantbirla@hotmail.com
Section G - Declaration
I declare that all information supplied is true and correct in every particular and that no information
material to the Applicant’s Financial Position has been omitted here from, and I acknowledge that if
Credit is granted by you, this will be done in reliance upon the information supplied by me herein, and
my acceptance of the conditions of sale (see overleaf). I agree to DIC India Limited, making enquires
of credit information providers concerning the creditworthiness of the Applicant. I also acknowledge
transmission as an attachment to an email from the Applicant’s representative noted below
constitutes a formal Application for Credit.
Representative of Name/Position Held Signature
Applicant Date:
Section H – Internal for Credit Assessor Only
Assessment Date Click or tap to enter a date.
Assessor Name
Rating Choose an item.
Credit Period 60
Credit Limit 500000 (Please indicator currency)
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