Customer Name*

Customer Mail ID*

Customer Contact No. for Backend to Call*

Business Name*

Address Line 1*

Address Line 2

Address Line 3

Current Location*

City*

State*

Pin Code*

Total Package Amount
Taxation
Yes
No
Invoice Name
GST No.
PAN No.
Invoice Address
Mode of Payment
Cheque
Online
Cheque Name
Cheque No.
Bank Name
Cheque Date
On Date
PDC
NA
Online Transaction ID
Registration Date
Upload Selfie*

Cheque Leaf or Online Transaction Screenshot*

Area Name*
BA Name*
BA Email*
BA Code*
BA Pan No.*
Page Status*
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[radio* radio-21 use_label_element default:0 "Publicly Not Visible"]
[radio* radio-21 use_label_element default:0 "Other"]
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