Docstoc

Proffessional Charges Agreement

Document Sample
Proffessional Charges Agreement Powered By Docstoc
					          221/A,Gohartaj building,First Floor,Dr. B. Ambedkar Road,Dadar (E), Mumbai –400 014.
                      (ALL THE INFORMATION SHOULD BE IN BLOCK LETTERS)

APPLICATION FOR       : _______________________________________________

AREA                  : _______________________________________________

PERSONAL INFORMATION                                                                 PHOTO
LAST NAME               : ______________________________________________

FIRST NAME              : ______________________________________________

MIDDLE NAME             : ______________________________________________

ADDRESS                 : _________________________________________________________________________

_________________________________________________________________________________________________

LANDMARK       : __________________________________________ CITY     : _______________________________

DIST   : _________________    STATE : __________________________ PIN         : ________________________

MOBILE NO.     : _________________________________ TEL. NO. : ______________________________________

E-MAIL ID: ______________________________________________________________________________________

PASSPORT NO ___________________________ PAN /GIR NO. __________________________________________

DATE OF BIRTH : ______________________ SEX: _________________ NATIONALITY : ___________________

ANNIVERSORY DATE : _______________________           SPOUSE NAME : _______________________________


PROFFESSIONAL INFORMATION

ANYBODY IN LIC
NAME : ________________________________________________________________________________________

DESIGNATION : _________________ CODE : ______________ BRANCH: _________ DIVISION ______________

OCCUPATION : _________________________________________________________________________________
(EXCEPT LIC)

NAME OF ORGANISATION/FIRM/COMPANY : _______________________________________________________

ADDRESS : ______________________________________________________________________________________

CONTACT NO. _______________________ DEPT.: ________________ NO. OF YEAR WORKING              : _________


ACHIEVEMENTS: ________________________________________________________________________________
REFERENCES
NAME: _________________________________________________________________________________________

ADDRESS: ______________________________________________________________________________________

OCCUPATION: _____________________ MOBILE: _____________________ TEL.: _________________________

NAME: _________________________________________________________________________________________

ADDRESS: ______________________________________________________________________________________

OCCUPATION: _____________________ MOBILE: _____________________ TEL.: _________________________


DOCUMENTS ENCLOSED

_________________________________________________________________________________________________

_________________________________________________________________________________________________


CUSTOMER DECLARATION

I/WE AGREE TO PAY THE ______________________________ REFUNDABLE SECURITY DEPOSIT AND ALL
CHARGES ASSOCIATED WITH THE SERVICES BY US/ME. I/WE HAVE READ AND UNDERSTOOD THE
TERMS AND CONDITIONS PROVIDED BY INFODEEP TECHNOLOGIES PVT. LTD. AND APPLICABLE
RATES FROM A PART OF THIS AGREEMENT AND I/WE AGREE TO BE BOUND BY THE SAME.




SIGNATURE: __________________________                           DATE: _______________________
SEAL OF THE FIRM (AS APPLICABLE)


FOR OFFICE USE ONLY

DATE OF SACTION      : _____________________

CATEGORY             : _____________________

AREA                 : _____________________

ADD. COMMENTS        : __________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________




SIGNATURE & DATE     : _______________________    SIGNATURE & DATE      : ________________________

ZONAL MANAGER        : _______________________    DISTRIBUTOR           : ________________________

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:3
posted:7/12/2011
language:English
pages:2
Description: Proffessional Charges Agreement document sample