DEALER
INFORMATION
FORM
Exclusive National Distributors for OptiMaser
Part A (Company Details)
Dealership Code: ______________
(To be allotted Post Selection)
Fix Self
Signed
A. Name of Company: ______________________________________________
Photograph of Key
Contact Person
B. Start Date of Establishment:
//
C. Type of Company: Private Ltd
 Public Ltd  Partnership  Proprietorship
D. Key Contact Person: __________________________________________________
E. Designation: _______________________ Mobile: +91
F. Regd. Office Address:
G. City:
H. Office Phone/s:
I.

_____________________________________________________________
___________________________ Pin Code:

____________________________Email: ___________________________________
Name of Proprietors/Partners/Directors
1. Name: ______________________________________ Designation: _________________________
2. Name: ______________________________________ Designation: _________________________
J.
Local Sales Tax No:_________________________________________ Dated______________________
K. Central Sales Tax No: _______________________________________ Dated ______________________
L. Tin No:__________________________________________________ Dated ______________________
M. List products distributed by your company (include your experience in CSSD, if any) –
Product Name
Product Type
OEM Name
Type of Contract
Year of Association
 Exclusive
 Non-exclusive
 Exclusive
 Non-exclusive
 Exclusive
 Non-exclusive
N. Major achievements of your company in last  3 /  6 /  12 months:
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________
Confidential.
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DEALER
INFORMATION
FORM
Exclusive National Distributors for OptiMaser
Part B (Company Infrastructure)
O. Branch Office (if any, Please give particulars in separate sheet). Provide locations here:
1. __________________ 2. ______________________ 3. __________________ 4. __________________
P. Office setup (in sqft): Office space _____________ Service space ____________ Storage ____________
Q. No. of Employees: Sales: ____________
Service: _____________ Others: ____________
Part C (Company Financials & Business Plan)
2013 - 2014
2014 - 2015
2015 - 2016
R. Turn Over (Rs. Lacs)
S. Requested State/Organizations: ______________________________________________________
Sales commitment for
FY 2016 - 2017
Quarter 1
Quarter 2
Quarter 3
Quarter 4
T. Target (Rs. Lacs)
Kindly attach a company profile along with the dealer information form.
I hereby certify that the above information given are true and correct as to the best of my knowledge.
Signatures &Stamp
Date:
For Office Use
(Fill in the below boxes as per company selection process)
1.
2.
3.
4.
Signatory, Name, Date
Confidential.
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