Dealership Application Form
Questions marked by * are required.
1.
Product Name(s) Dealership applied for *
LOM-C Strong
LOM C CD
DFA C Strong CMB
QOWDC
2.
Applicant's Name with father name *
3.
Business name if any
4.
PP Photo of Applicant
5.
Age of Applicant in years *
6.
Full Postal Address of Applicant in India with District, State name and Pin code *
7.
5 Villages names with Postal Pin Code applied for Dealership *
8.
Do you have agriculture background? *
Yes
No
A litte
9.
Mobile Number(s) *
10.
Have You fully read our Website? *
-
Yes
No
Not yet
11.
Your Reference Person's Name Address with Phone Number if any
12.
Type of Mobile phone the Applicant is having *
-
Android Phone
Button Phone
13.
Email if any *
14.
Investment Proposed in Rupees *
15.
Do You agree to collect Feedback about our Products from Farmers and submit to us? *
Yes
No
No Idea
16.
Any other Information or Suggestions?