SRMB Udyog Limited

AGENT DATA FORM

Fields with * are mandatory.

Agency Details:
Name: *
Address: *	(PIN)
Contact Person *
Telephone/Fax *	(Phone) (STD code) (Mobile) (Fax)

Agency Establishment Detail:
Office & Equipment Facility *
Car / Mobility *
Staff *

Business Detail:
Current Business Activity
Business Volume / Annum
Business Expected

Business Preview:
Principle COS.
Payment Terms
Turnover Last 3 Years
Customer List

References
Name 1
Company & Designation
Contact Nos
Name 2
Company & Designation
Contact Nos
Turing Number