APPLICATION FOR REGISTRATION AS DEALER Name: Opted for: X-Trend BlowHot Name of the Firm: Address: City: State: Andaman & Nicobar Islands Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhatisgarh Dadra & Nagar Haveli Daman & Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu & Kashmir Jharkhand Karnataka Kerala Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha (Orissa) Puducherry (Pondicherry) Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal Pin Code: Landline: Mobile: Fax: Email: TIN(TOT): CST: Service Tax Registration Number: PAN: Residential Address of partners / Directors with name and Telephone Number: Nature of present Business: Shipping Address: Name of the Bank: Account Number: Bank Address: