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Dealership Application Form
Questions marked by * are required.
1. Product Name(s) Dealership applied for *
  • Liquid Organic Manure Concentrate
  • Cow Milk Booster Concentrate
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? *
11. Your Reference Person's Name Address with Phone Number if any
12. Type of Mobile phone the Applicant is having *
13. Email if any
14. Investment Proposed in Rupees
15. Any other Information or Suggestions?