D-Pan

Name of the Company/ Owner/ Firm

ID Proof Details (Photo Attachment system of Aadhar / Driving License / Voter ID or any Govt, authorized ID)

Address : At

Po :

Dist :

Pin :

State :

Country :

Nearest Location / Landmark :

Mobile No 1 :

Mobile No 2 :

Email Id 1 :

Email Id 2 :

Website if any :

Type of Machine :

Regd. Certificate / Sl. No. / Bill /other (Attachment System)

Attachment system of machine photo (every 4side, 5 No) :

Attachment system of machine working video ( Direction to Regd. No / Sl.No / Chassis No/ Other Clearly visible) :

Type of Supply / Fuel :

More details about Machine. Company, Capacity and other details within the minimum words :

Account Details : A/C No

IFSC Code :

Account Holder Name :

Name of the Bank :

Branch :

Self Declaration : (Including legal warning) :