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DSA Empanelment Application Form

The document is an application form for empanelment as a Direct Selling Agent or Direct Marketing Agent with Can Fin Homes Ltd. It requests information such as name, address, qualifications, expected business targets, and requires submission of documents like PAN card, address proof, and bank statements.

Uploaded by

Raj S
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59 views2 pages

DSA Empanelment Application Form

The document is an application form for empanelment as a Direct Selling Agent or Direct Marketing Agent with Can Fin Homes Ltd. It requests information such as name, address, qualifications, expected business targets, and requires submission of documents like PAN card, address proof, and bank statements.

Uploaded by

Raj S
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

Annex-3

APPLICATION FORM FOR EMPANELMENT OF DSA / DMA

To

The Manager,
Can Fin Homes Ltd
(Address)

Sub: APPLICATION FOR EMPANELMENT AS DIRECT SELLING AGENT (DSA) /


DIRECT Marketing agent (DMA) WITH CAN FIN HOMES LTD.

I submit herewith my application for the empanelment a Direct Selling Agent (DSA) / Direct
Marketing Agent (DMA) for Can Fin Homes Ltd. I have read the terms and conditions
relating to the service and I undertake that those are acceptable to me.

1 Full name (in block letters)

(Name of the
individual/Proprietorship
Firm/Partnership/Company

2 Father’s / Husband’s Name


3 Constitution Individual Proprietorship Partnership Company
(tick appropriate option)

4 Date of birth /
incorporation
(DD/MM/YYYY)
5 Age Years Months
6 Address

7 Mobile number
8 Alternate contact number
9 E-mail id
10 i) PAN card no.

ii) Aadhar card no.

11 Present occupation
12 Income (Proof to be
provided)
13 No. of years in
employment
14 Qualification
15 Languages known
16 Command area to be
covered
17 Reference 1.
(name, address and
contact number)
2.

18 Business
Expected business to be No. of A/cs Amount (in [Link])
canvassed per month

19 Whether an assessee of
IT…
Yes/No.
If yes, GST/TIN No……….

I declare that the statements in this application and the documents submitted (as per list
given below) are true, complete and correct to the best of my knowledge and belief.
I declare, that no criminal proceedings are pending against me. I further declare that I am
not related to any existing employee of Can Fin Homes Ltd. I understand that in the event
of any information / document being found untrue / incorrect at any stage, my application is
liable to be rejected and if already empanelled, the empanelment is liable to be terminated.

Place: Signature:
Date: Name:

Documents to be submitted along with application:

1) Copy of PAN & Aadhar card.


2) Address proof (latest telephone/mobile bill, electricity bill, gas bill, passport or ration
card).
3) Two recent passport size photographs (in addition to one affixed on application form).
4) Latest IT return/Form 16.
5) Bank statement for last 6 month.
6) Enrolment letter, if enrolled with other bank/FI for similar services.
7) In case of firm / Company: Registration certificate of firm & Partnership deed/Articles of
Association of the company and incorporation certificate.

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