Agoraindia

Vendor/Franchise Registration

Agoraindia.in

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LAVISH HEALTH CARE PVT. LTD

Associate Registration Form 

Company Contact

Name of the Company

Business Address

Legal Status

Sole Proprietorship

Partnerhsip

Private Co.

Public Listed Company

Public UnListed Company

Limited Liablity Partnership

Limited Liablity Partnership

Any Other (Please Specify)

PAN

GSTIN No.

MSME Registration No.

Contact Person Name

Contact Number

E-mail Address

BANKING INFORMATION

Bank Name

Bank Address

Benificary Name

Account Number

IFSC CODE

CERTIFICATION

I hereby affirm that all information supplied is true accurate to be best of my knowledge and belief and Notice must be given of any change in status impacting the information provided within 15 days of said change

Authorizing Person Name

Title

Date