Name:______________________________________________________
Address:____________________________________________________
Nominee : ______________________ Relation:____________________
City: ______________ State: ____________ Pin: __________________
Phone: _____________________ E-mail:__________________________
 

Payment Details

Cash / D.D. Rs. _________________ (Rupees ____________________ Bank Name: _________________ Branch: _________________
D.D.No. __________________ Date ____________________________
Number of IDs _____________ in words _________________________
 

Reference Details

Sponsor's Name:____________________________________________
Sponsor's ID: _________________________________________________________
 

Acceptance

I confirm that I have read and understood the Terms & Conditions (overleaf) of "J&S 5" of Jain & Sons Super Markets Pvt. Ltd. I fully agree to become a Business Associate of "J&S 5" plan by paying an amount of Rs.300/- per entry to Jain & Sons Super Markets Pvt. Ltd.

Place: ____________________

                                                             _____________               
Date: ______________                             Applicant's Signature

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For Office Use Only

Received by: _________________ Date:___________________