Commercial Tax Department FORM-A APPLICATION FORREGISTRATION ASDEALER [See rule 3(2)] To ThegserigAhriy__________ eRitnutot__________ 2.Address: a. Pniaricpl place of busnsies b. Branch c. Factory d. Godown BuildingName Door No. Street/Road Vil age/ Commune/ City PIN 3.Adresfheaieosdhae dsote HdOf cutie te Stt 4.osiuto5Biesrascin Cnttin .usnsTnato Proprietor Partnership Private LimitedCompany PublicLimitedCompany HUF Co-operative Society GovernmentUndertaking Others CustomsRegistrationBIN IndustryRegn. No./SSI/MSI/LSINo. Central Excise Regn.No. Registrar ofCompany'sCIN PropertyTaxAssessment no.,ifany Income TaxPAN Director General ofForeign Trade'sI.E.C. Name ofthe Bankand Accountno. 6.roale/Dtfoctfbies Pbbaeocmmenemenousns: 7.alsote Ppetr /Prters/Direco,c Detifhrorioantrset. Ettxenfo hsareor itnerestin biusness (7) Permatnen dadress (6) Ptresen Address (5) Sttaus (4) Nameof Fhtaer (3) Age (2) Name (1) Sitgnaure (14) VtoerID No. (13) Ritaon CardNo. (12) Ptasspor No. (11) PAN (10) Bkan Actcoun No. (9) Bankwhere accountis iavalbalewiht BankCdoe (8) 8.Telephone No. 9.FaxNo. 10.-Mal I EiD 11.Websie: t 12.Nature of Busns ies 13.Turnover onthe date ofthisapplication 14.Maincommoditiesdealt/tobe dealt 1. 2. 15. Sourcesofpurchase : Withinthe State Inter-State Importfrom outside the country 16.alsoivbroert,fn,or: Detifmmoaleppyiayf (i) Biessusn (i Ppetr/) rorioPartner/ Ditrreco Location SurveyNo. Extentof land/area Registration Doc.No.& Year Registration jurisdiction *efcfraeAscainoworesecalepos/usnsi 17.*RereneoTdsoitortptbersnbiesnthe apliats a pcn'rea 1 2 Name of the business Address Name ofthe person recommending Status TIN Signature with seal **Tedalsreqredioeedntefihytedlerswhsitto hetiuinclumn17noburnsedbheaoe regsrain isinforce under the PGST Act,1967. 18.amendalsoregsrainf Pytetifittoee: Amount DD/Crossedcheque /Banker'scheque No./CashReceipt No*. Date Name ofthe Bank Branchcode *ifpitahcuner iheprttremies.adacsotntedamenpsDECLARATION I/We ________________________S/o__________________________ doherebydeclare thtte prtcrsfihbvnte apctore totadcmpe th ahaiulaurnsedaoe ihpliainarue,crrecnoletote besomykogneli. tfnwlede adbef Place: Signature ofthe applicant : Date : Name andDesignation/Status andRelationshiptothe dealer withseal
