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Agent Details:

Note - For Photo,Pan and Aadhaar only jpg,png,jpeg Files are allowed having size less than 100KB

Applicant Type *

Name *

Father's Name *

State

District *

Tehsil *

Permanent Address *

Photograph *

PAN Number *

PAN Copy *

Aadhaar Number *

Aadhaar Copy *

Email *

Password *

Confirm Password *

Mobile *

Registration Fee (INR) *

Payment Date*

PNB Collection Code *

Has your registration request ever refused in past?

NoYes

Has your registration request ever revoked in past?

NoYes

Name *

Photograph *

Address *

Aadhaar Number *

Aadhaar Copy *

PAN Number *

PAN Copy *

Email *

Mobile *

Bank Details:

Account Number *

Account Name *

Bank Name *

IFSC Code *

Branch Name *

Branch Address *

Documents:

Income Tax Returns *

Remark

Address Proof *

Remark

Agent Details:

Chief Executive Officer Details:

Bank Details:

Documents:

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