NEXUS POLYCHEM

PLOT NO. 9 & 10, IIIRD PHASE, STICE, MUSALGAON,

TAL-SINNAR, DIST-NASHIK-422112, TEL-02551-240079, MOB:- +91 8888861893

VENDOR/ SERVICE PROVIDER REGISTRATION FORM

Doc No. : 2017-18/ Date :

Sr. No. Particulars Details
1 Company Name :

2 Company Type : Proprietor / Partnership Firm / Private Ltd Co. / Listed Co. / Other

3 Office / Correspondence Address :

Principal Place Of Business (As per GST Regn.) :

4 (Kindly use separate sheet for each
Principal Place of Business)

5 State of Registration :
6 State Code :

Delivery / Godown / Depot Address :

7
(if different from Principal Place of Business)

Product Name & HSN Code :

8 (Kindly attach separate sheet if more than one
product)
9 Tel. No. / Mobile No. :
10 Fax No. :
11 Email ID :

12 Director / Proprietor Name :

13 Contact Person Name & Designation :

14 Category : Manufacturer / Dealer / Distributor
15 Company Annual Turnover :
16 ISO Regn. No. & Date, if any :
17 MSME/SSI Registration No., if any :
18 PAN No. :
19 Local TIN No. :
20 CST TIN No. :
21 Central Excise Details
22 (a) Excise Registration No. (ECC No.) :
(b) Range :
(c) Division :
(d) Commissionerate :
23 GST Provisional ID / GSTIN No. :
24 ARN Alloted upon GST Registration :
25 Service Tax No. :
26 Bank Account Details
(a) Account Number :
(b) Bank Name :
(c) Branch Name & Address :
(d) Account Type : Current / Savings / Others ________________
(e) IFSC Code :
(f) MICR Number :

List of Documents enclosed herewith :

1 PAN Card copy
2 VAT & CST TIN Certificate Copies
3 Excise Registration Certificate Copy (if applicable)
4 GST Provisional Regn. Certificate / Acknowledgement
5 Cancelled Cheque copy

I, _______________________ (Name of the authorised person), working as ____________ (Designation) declare that the above given information is
true & correct.

For _______________________

(Sign with company stamp)

FOR OUR OFFICIAL PURPOSE

Payment Terms : _________________________

Credit limit, if any : ________________________

_________________
Approved by
 NEXUS POLYCHEM
PLOT NO. 9 & 10, IIIRD PHASE, STICE, MUSALGAON,
TAL-SINNAR, DIST-NASHIK-422112, TEL-02551-240079, MOB:- +91 8888861893

VENDOR/ SERVICE PROVIDER REGISTRATION FORM

Doc No. : 2017-18/ Date :

Sr. No. Particulars Details
1 Company Name :

2 Company Type : Proprietor / Partnership Firm / Private Ltd Co. / Listed Co. / Other

3 Office / Correspondence Address :

Principal Place Of Business (As per GST Regn.) :

4 (Kindly use separate sheet for each
Principal Place of Business)

5 State of Registration :
6 State Code :

Delivery / Godown / Depot Address :

7
(if different from Principal Place of Business)

Product Name & HSN Code :

8 (Kindly attach separate sheet if more than one
product)
9 GST Provisional ID / GSTIN No. :
10 ARN Alloted upon GST Registration :
11 PAN No. :
12 Tel. No. / Mobile No. :
13 Fax No. :
14 Email ID :

15 Director / Proprietor Name :

16 Contact Person Name & Designation :

17 Category : Manufacturer / Dealer / Distributor
18 Company Annual Turnover :
19 ISO Regn. No. & Date, if any :
20 MSME/SSI Registration No., if any :
21 Bank Account Details
(a) Account Number :
(b) Bank Name :
(c) Branch Name & Address :
(d) Account Type : Current / Savings / Others ________________
(e) IFSC Code :
(f) MICR Number :

List of Documents enclosed herewith :

1 PAN Card copy
2 GST Registration Certificate / Acknowledgement
3 Cancelled Cheque copy

I, _______________________ (Name of the authorised person), working as ____________ (Designation) declare that the above given information is
true & correct.

For _______________________

(Sign with company stamp)

FOR OUR OFFICIAL PURPOSE

Payment Terms : _________________________

Credit limit, if any : ________________________

Compliance Rating :____________________________ _________________

Approved by