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Distributor
IN263835 DATE: 08/FEB/2020 18:31:03
ID No.:
REFERRER INFORMATION
Referrer ID: IN631493 Referrer Name: VINITA KHATURIA
APPLICATION INFORMATION
Title (If Individual) Mr./Mrs./Ms: Business Name (If not individual):
MR. N/A
Surname, Given Name (If Individual): Contact Person (Business Entity):
YADAV; VINAY RAMLALJI N/A
Mailing Address: Cheque Name (Name on the commission cheque):
S/O RAMLALJI, VILLAGE NAGLA GURUDAYAL, DHAURRA VINAY RAMLALJI YADAV
AGRA AGRA UTTAR PRADESH 283202 India (Vihaan)
Shipping Address: Home Phone No & Mobile No:
S/O RAMLALJI, VILLAGE NAGLA GURUDAYAL, DHAURRA 918126704606; 918126704606
AGRA AGRA UTTAR PRADESH 283202 India (Vihaan)
Valid ID Type / ID Number: eMail Address:
PAN Card/ BTQPJ5558J VINAYYADAV112211@GMAIL.COM
Nationality & Date of Birth: Mother's Maiden Name:
INDIA; 11/NOV/1996
Name of Beneficiary/Nominee: Relationship to the Beneficiary/Nominee:
RAMLALJI Father
Date of Birth of Beneficiary/Nominee:
01/JUL/1970
1. For business entities, an authorised signatory of the company must sign this Distributor Application Form. Received By: _______________
2. You must be 21 years old and above to become a Distributor.
3. By signing below. you certify and acknowledge that you have read and agreed to be bound by the Policies Received Date: _______________
and Procedures.
4. I agree to adhere to the Know Your Customer ( KYC ) requirements as requested by Vihaan Direct Selling Processed By: _______________
(India) Pvt Ltd.
Processed Date: _______________