Registered Business Name of Reseller
Registered Address
Delivery Address
Traning / Billing Address
Type of Business Entity	Sole Proprietorship Partnership Pvt. Ltd. Company Public Ltd. Comapny
Central Sales Tax No. & Date	No.   Date Month Year
Local Sales Tax No. & Date	No.   Date Month Year
Tin No. & Date	No.   Date Month Year
Income Tax Pan No.
Date of Commencement	Date Month Year
Tel No.
Fax. No.
Cell No.
Email
Details of	Proprietor Partners Directors
Name Home Address & Tel. Nos. Qualifications Ownership%
Contact Names Tel. Nos. Fax. Nos. Accountant Accounts Payable Director / Dealer Principle Finance Head Purchasing Officer Sales Manager
Organisation Structure	No. of Employees Management Staff
Description of Business
Type of your Customer Profile	Reseller Goverment Corporates End User Sys. Integ. OEM's
Bank Details
Bank Name
Bank Address
A/c No.
Credit Limits (If any)
Contact Person
Tel. No.
The applicants undertakes to provide advance intimation to Pacific Brands before closure of any bank A/c from which cheques have been issued