KOLKATA PORT TRUST
KOLKATA DOCK SYSTEM
CUSTOMER REGISTRATION FORM
[FORM TO BE FILLED UP BY TYPING, SIGNED AND SUBMITTED TO
KOLKATA DOCK SYSTEM
(USE BLOCK CAPITAL)
I. COMPANY NAME:
GROUP: (USE √ MARK) GOVT SEMI-GOVT
CORPORATE OTHERS
II. A. FULL BILLING ADDRESS:
PIN CODE:
III. A. ADDRESS OF REGISTERED OFFICE OF COMPANY/ENTITY:
PIN CODE:
Fax Number (With STD Code): [ ][ ]
IV. PERMANENT ACCOUNT NUMBER (PAN):
GST IDENTIFICATION NUMBER (GSTIN):
V. TAX DEDUCTION ACCOUNT NUMBER (TAN):
VI. INCOME TAX CIRCLE :
VII. a. CUSTOM HOUSE AGENCY CODE
(if any) : (Mandatory for C&F Agents)
b. HOUSE AGENCY LICENSE NUMBER
(Mandatory for C&F Agents)
c. Kolkata Port Trust Registration Number
(Mandatory for Steamer Agents/C&F Agent)
VIII. CUSTOM HOUSE AGENCY VALIDITY UPTO :
(if any) (Mandatory for C&F Agents)
IX. TELEPHONE NUMBERS OF CONTACT OFFICE: 1
WITH STD CODE 2
3
EMAIL:
X. FAX NUMBERS OF CONTACT OFICE
[WITH STD CODE]:
XI. TYPE OF OPERATION: [PLEASE (√ )TICK ONE OR MORE AS APPLICABLE]
STEAMER AGENT MAIN LINE OPERATOR
BARGE OPERATOR CHARTERER/ AGENT
C&F AGENT CARGO HANDLING AGENT
IMPORTER/EXPORTER SURVEYOR
STEVEDORE/SHORE HANDLING AGENT CFS/ICD OPERATOR
LESSEE/LICENSEE ELECTRICITY CONSUMER
OTHERS [Specify]
XII. BANK ACCOUNT DETAILS [for effecting refund through bank directly]
a Bank Name
b Bank Account Number
c Account Type : (Cash Credit/Current/Savings)
d Branch Name:
e Branch Address (Full with PIN code):
f Eleven digit RTGS Code Number of the Branch
g Nine digit MICR Code Number of the Branch:
h Phone Number of Branch
i Fax Number of Branch
I/We declare that the above particulars are true to the best of our knowledge and has been furnished
after due verification of relevant records. We also undertake that we would notify Kolkata Dock
System about any change in the above particulars as and when it occurs. It is also confirmed that the
undersigned is duly authorised by the Company/firm to deal with all matters with Kolkata Dock
System including signing such declaration/confirmation. We also accept that KDS shall not be
responsible for delay in credit of refund in our A/C (mentioned above), attributable to Banks. Further,
we shall be solely responsible for any eventuality arising out of incorrect and/or incomplete
information being furnished by us above. We also undertake to intimate KDS about any change by
filling up a separate form immediately.
Enclo: 1. Copy of PAN Card & GSTIN Certificate (For all)
2. Copy of Custom House Registration Certificate
Indicating Code No, License No & Validity
(For C&F Agents Only)
3. Registration Certificate of Kolkata Port Trust.
(For Steamer Agent & C&F Agents)
Signature of Authorized Signatory
Full Signature with
Name and Designation
[Put Rubber Stamp of Company]
Date:
Confirmation from Bank with sign and seal
To be furnished over the Letterhead of the Company/Firm]
[Submit three copies all in Original]
CUSTOMER REGISTRATION FORM
KOLKATA DOCK SYSTEM
DETAILS OF AUTHORISED SIGNATORIES
Name of Company:
I. OPERATIONAL MATTERS:
Name Designation Specimen Signature TEL. NO., MOBILE NO. & E-
[To be signed by Black Ball MAIL ADDRESS
Point Pen]
Tel:
Mob:
Email:
Tel:
Mob:
Email:
Tel:
Mob:
Email:
II. FINANCE RELATED MATTER INCLUDING DRAWAL OF REFUND CHEQUE/
SIGNING DECLARATION / GIVING UNDERTAKING (Binding the Customer):
1. Signing Declaration and Giving undertaking on behalf of the Company:
Name Designation Specimen Signature TEL. NO., MOBILE NO. & E-
[To be signed by Black Ball MAIL ADDRESS
Point Pen]
Tel:
Mob:
Email:
Tel:
Mob:
Email:
Tel:
Mob:
Email:
2. Collection of Bills/ Treasury Receipts / Refund Cheques Other Miscellaneous Financial
Matters
Name Designation Specimen Signature TEL. NO., MOBILE NO. & E-
[To be signed by Black Ball MAIL ADDRESS
Point Pen]
Tel:
Mob:
Email:
Tel:
Mob:
Email:
Tel:
Mob:
Email:
Note: Any change in the above shall have to be notified by giving similar declaration.
Signature with Name and Designation
Date:
Encloses: Copy of Power of Attorney of the signatory.
[TO BE FURNISHED IN LETTERHEAD OF THE COMPANY]
REQUEST FOR CHANGE IN BANK PARTICULARS
FOR RELEASE OF REFUND CLAIM AS WELL AS PAYMENTS AGAINST BILLS
We hereby submit the following particulars of our Bank for forwarding payment against Bills as well
as release of refund (when introduced) in our account, from Kolkata Dock System. The earlier details
furnished may be amended.
I. BANK ACCOUNT DETAILS [for effecting payment/ refund through bank directly]
a Bank Name
b Bank Account Number
c Account Type : (Cash Credit/Current/Savings)
d Branch Name:
e Branch Address (Full with PIN code):
f Eleven digit RTGS Code Number of the Branch
g Nine digit MICR Code Number of the Branch:
h Phone Number of Branch
i Fax Number of Branch
I/We declare that the above particulars are true to the best of our knowledge and has been furnished
after due verification of relevant records. We also undertake that we would notify Kolkata Dock
System about any change in the above particulars as and when it occurs. It is also confirmed that the
undersigned is duly authorized by the Company/firm to deal with all matters with Kolkata Dock
System. We also accept that KDS shall not be responsible for delay in credit of payment/ refund in
our A/C (mentioned above), attributable to Banks, when such facility is introduced.
Signature of Authorized Signatory
Full Signature with
Name and Designation
[Put Seal of the Company]
Date:
