CHANNEL PARTNER EMPANELMENT FORM

Latest
Photograph
of
Authorized
Signatory
1. Name of Company / Individual (in capital letters) : Mr./Ms./Mrs./M/s
..................................................
.........................................................................................................................................................
2. Name of Authorized Signatory (in capital Letter)
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3. Father's / Husband's Name: (In case of individual) .........................................................................
4. Type of Organization: Proprietorship / Partnership Firm / Company / Trust / HUF / Others
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5. Name(s) of Proprietor / Partners / Directors
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6. Present / Mailing Address:
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Contact No: .......................................................... E-mail : ..............................................................
7. Permanent / Registered Office Address:
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Contact No: .......................................................... E-mail : ..............................................................
8. Permanent Account Number (PAN) :
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Income Tax Assessment Particulars : Ward .................................... Place
........................................
Company Registration No. (In case of a Company) :
.........................................................................
Passport No. (In case of Individuals) : ...............................................................................................
9. GST Number : ...................................................................................................................................
10. RERA Registration Number : ............................................................................................................
11. Business Experience : ......................................................................................................................

S. Details of the Area Sold Period

Project / Project Value
No. Project (Client (in Sq. Ft) From - To
Site
etc)
12. Other Work Experience :

(i) ........................................................................................................................................................

(ii) .......................................................................................................................................................

(iii) .......................................................................................................................................................

(iv) .......................................................................................................................................................

(v) .......................................................................................................................................................

13. Details of Infrastructure :-

a) Office Location & Branches :

......................................................................................................

b) Owned/Leased : .........................................................................................................................

c) Floor Area : .................................................................................................................................

d) Number of Employees : .............................................................................................................

14. Financial Information for the last three years:-

(Amount in Rs.)

Year Sales / Turnover Profit Before Tax Profit After Tax

15. Name & address of two references:

(I) Name : ................................................... Address : ........................................................................

Relationship : ......................................... Telephone No/Mobile No.

...............................................

(ii) Name : ................................................... Address : ........................................................................

Relationship : ......................................... Telephone No/Mobile No.

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16. Are you Related to anybody in Hero Enterprise ? Yes / No. If yes:

Name: ……………………………….…… Department : .................................................................

Relationship: …………………………...... Company: ....................................................................

17. Have you got any previous record of any legal proceedings (civil and/or criminal) instituted

either against you or your organization? Yes/No, If yes, give details

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18. Have you/your partners/directors ever been arrested by police or prosecuted by any court?

Yes / No. If yes, give details

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19. Is there any litigation pending against you filed by any organization where you have rendered

services? Yes/No. If yes, give details

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........................................................................................................................................................

20. Have you ever filed any case against an organization where you have rendered services?

Yes / No. If yes, give details

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I hereby solemnly declare and affirm that the particulars and information given above are true and
correct and that I have not knowingly withheld any fact or circumstances. I also understand that in
case of willful mis-statement or concealment of any material fact, my services are liable for
immediate termination without payment of any fees for the services rendered.

Date

Place Signature with Seal

Kindly furnish the documents mentioned below :

• Copy of PAN and GST Number

• MOA/AOA in case of Company along with board resolution/POA in favor of

authorized signatory
• Partnership deed in case of partnership firm

• RERA Registration Number