CUSTOMER REGISTRATION FORM

Customer Name (Legal Name)* Jodhpur Healthcare Pvt Ltd

Registered Address* Jodhpur Healthcare Pvt Ltd
E-4,MIA,Basni 2nd Phase,Jodhpur
Rajasthan

City Jodhpur Zip Code 3 4 2 0 0 5

State Rajasthan Country India
PAN of the Customer* AACCJ9336P
Contact Person* Mr.KHS Shekhawat Phone* 0291-2723486

Email Id* shekhawat_erhs@poornima.org' Mobile* 9893114572

SHIPPING ADDRESS
Type of Project* o New Installation / MOD o Maintenance o Repair / Supply of Spare
Project Name* Jodhpur Healthcare Pvt Ltd
Shipping Address* Jodhpur Healthcare Pvt Ltd
E-4,MIA,Basni 2nd Phase,Jodhpur
Rajasthan

City Jodhpur Zip Code 3 4 2 0 0 5

State Rajasthan Country India
Service Tax No. VAT TIN
TAN (Income Tax) TAN (WCT)
CST No.
Contact Person* Mr.KHS Shekhawat Phone* 0291-2723486

Email Id* shekhawat_erhs@poornima.org' Mobile* 9893114572

BILLING ADDRESS* o Registered Address o Shipping Address o Any Other(Pls Specify Below)
Customer Name Jodhpur Healthcare Pvt Ltd
Billing Address Jodhpur Healthcare Pvt Ltd
E-4,MIA,Basni 2nd Phase,Jodhpur
Rajasthan

City Jodhpur Zip Code 3 4 2 0 0 5

State Rajasthan Country India

Information in case of E1 transaction

Consignee/ End user
Consignee's address

VAT TIN CST No.

City Zip Code

State Country

DECLARATION

I/We hereby declare that the above information is true and correct to the best of my/our knowledge

Customer's Signature & Stamp

Name :
Designation :

For ThyssenKrupp Elevator (India)

Project Name Jodhpur Healthcare Pvt Ltd

Job No.
CUID

Name Utkarsh Kansoria

Designation Executive-Sales
Department NI-Sales
Date 9/12/2013 Signature

Fields Marked * are compulsory