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City

State

Date

Name Of the Firm

Address

Contact No

Current Location

Name of Proprietor/Partner/Director

Income Tax PAN No

Name of the Key Person

Weekly Closing Day

Tin Number

Bank Name & Address

Bank Account Number

Godwon Facilities Available Size

No. of Outlets Covered

Hired Or Own Cycle/van/3 wheeler

Market Working System

Area Coverage

RDS Head Quarter Off