Dealer/Distributor Application Form

Company/Organization Name:(Required)

Name of Business Owner:(Required)

Age(Required)

Gender:(Required)

Male

Female

Others

Nationality:(Required)

Applicant Permanent Address:(Required)

Applicant Current Address:(Required)

Phone(Required)

National ID Number:(Required)

Tax Identification Number (TIN):(Required)

VAT Registration Number:(Required)

Trade License No:(Required)

Division(Required)

District(Required)

Thana(Required)

Current Business/Distributions Status:(Required)

Proposed Business Area Demarcation:(Required)

Description of warehouse:(Required)

Manpower/ Employee Details:(Required)

Dealer Logistics & Vehicle Details:(Required)

Mode of Payment you wish to Maintain:(Required)

Cash

Cheque

Online

Currently your company deals through any bank(Required)

Reason for Interest in AZMIRA:(Required)

Reference:(Required)