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Channel Application Form

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mkappergst
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14 views3 pages

Channel Application Form

Uploaded by

mkappergst
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Channel Application Form

Date Location

Empanelment DSA/Connector

Name of the vendor

Partner
Individual HUF
ship
Legal Entity Type (Pl tick)
Proprietorship LLP PVT.LTD

Registered Office Address

Current Office Address

Mobile
Number
Communication Links Email ID
Mobile
Number

Designa
Sno Name Address
tion

Name & Address of


Individual/Proprietor/Partners
/Directors Mobile No

Channel Seal & Signature


Channel Application Form

Number of
years in
business
Number of
years in
current
business
PAN No.
GST., If Yes Yes/No
(Copy
Required)
MSME., If Yes Yes/No
(Copy
Required)
Annual
Turnover in
Crs.
Infrastructure No of Offices Office Space (Sq.Ft)

No of Staff No of PC
Bank Details Name of the Bank
Name of the Branch
Branch Address
City
Pincode
State
IFSC Code
MICR Code
Name as per Bank Account
Account Number
Account Type
Authorised Name of the Authorised
Signatory Signatory
Details Designation
Aadhaar No
PAN No
Address
Mobile Number
Business Name
Reference Mobile
(2 References)
Name
Mobile

Channel Seal & Signature


Channel Application Form

Has the Applicant/Promotors been associated with CUB At Any Point in time? if so, Please Give Details).

I/We here by authorize and give consent to the Bank to disclose, without notice to me/us, information furnished
by me/us in application form(s)/related documents executed in relation to the Channel Empanelment from the
Bank, to the Banks other branches/subsidiaries/affiliates, Credit Bureaus/Rating Agencies, Services Provides,
banks/ financial institution governmental/regulatory authorities of third parties for KYC information verification,
credit risk analysis, or for other related purposes that the Bank may deem fit. I/We waive the privilege of privacy
and privity of contract.

AUTHORISED SIGNATORY

Name:

Title:

Email id:

Date :

Channel Seal & Signature

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