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Agent Enrolment Form

The document is a registration form for customer service points (MSP, MSD, MRD) for Mobisafar Services Pvt. Ltd. It collects applicant information, shop details, permanent address, business information, banking information, and identity/address proof. The form includes declarations regarding terms and conditions, criminal record, and verification by Mobisafar employees.

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sudheerverma80090848
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37 views1 page

Agent Enrolment Form

The document is a registration form for customer service points (MSP, MSD, MRD) for Mobisafar Services Pvt. Ltd. It collects applicant information, shop details, permanent address, business information, banking information, and identity/address proof. The form includes declarations regarding terms and conditions, criminal record, and verification by Mobisafar employees.

Uploaded by

sudheerverma80090848
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PHOTO

WITH PLAIN
BACKGROUND
CUSTOMER SERVICE POINT
(MSP, MSD, MRD) REGISTRATION FORM

CSP Code: Distributor Code:


APPLICANT INFORMATION
Name of the Applicant: Date of Birth: D D M M Y Y Y Y
Gender : c
Male c
Female Education:
SHOP DETAILS
Name of the Establishment:
Outlet Address:
Landmark: City: State:
Pin Code: Tel No.: Mobile No.:
E-mail ID: Rented/Owned: Years in Location:
PERMANENT ADDRESS
Residential Address:
Landmark: City: State:
Pin Code: Tel No.: Mobile Number:
Email-ID.: Rented/Owned: Years in Location.:

BUSINESS INFORMATION
Description of services at present Outlet:
If you are having similar Arrangement with any other Bank, Society or BC please provide relevant details:
PAN No. Adhaar Number
BANKING INFORMATION
A/c with Bank A/c Number IFSC Code
IDENTITY PROOF
c
Passport c
PAN Card c
Voter ID card c
Adhaar Card c
Driving License c
Other (Specify)
ADDRESS PROOF
c
Passport c
Voter ID Card c
Adhaar Card c
Latest Bank Statement c
Other (Specify)

Payment Detail Amount: Cash Online c


c Transaction No:
MSP, MSD, MRD DECLARATION

I. I have read and understood the terms & conditions provided with the from and agree to all the terms and conditions listed on the mobisafar point' website.
II. I have been provided a copy of detailed terms & condition as well.
III. I have understood all particular of the investment plan chosen by me, trading process, margins and related terms MSP, MSD, MRD
& conditions at which services are provided by Mobisafar as applicable on this date as amended from time
to time.
IV. I confirm that the information(s) & particulars supplied by me are correct in all respects.
Name & Signature
V. I hereby declare that I do not have a Criminal record.
VI. I allow Mobisafar to debit Monthly / Yearly maintenance charges.

Name: Date: D D M M Y Y Y Y
EMPLOYEE, MSD DECLARATION
I hereby confirm that this form was signed by the MSP in my Presence and I have physically seen and verified the document(s) attached here with their respective original(s).

Mobisafar Employee / MSD: Employee / MSD Code:


EMPLOYEE / MSD
LAT/LONG..................................................................................................

Note: * Address Proof should match with either Outlet Address or Permanent Address

* Retailer should sign on all the pages on MSP form with rubber stamp Name & Signature

Mobisafar Services Pvt. Ltd. | Lower Ground Floor, Galaxy Tower, G.T. Road, Dholewal, Ludhiana, Punjab-141003, Ph. 0161-5015050
E-mail: care@mobisafar.com | Website: www.mobisafar.com

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