Apply to become a Domestic Distributor

Application Form

  • ADDRESS:

  • Contact Details

  • CONTACT PERSON

  • FINANCIAL DETAILS

  • BUSINESS DETAILS

  • NATURE OF BUSINESS
  • PRODUCTS CURRENTLY HANDLEDHANDLED SINCE (DATE)AREA / TOWNSAVERAGE MONTHLY TURNOVER (Rs Lakh) 
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  • EXPERIENCE IN RICE TRADE
  • VARIETYHANDLED SINCE (DATE)MONTHLY TURNOVER (Rs Lakh) 
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  • DISTRIBUTION AND INFRASTRUCTURE DETAILS

  • Net Worth Statement

  • I ___________________S/o___________________________ Resident of ________________________________________ Propreitor/partner/Director of _____________________ do hereby solemnly affirm and declare as follows:

    That following are my statement /details of assets & liabilities as on_________________________
  • DETAILS OF IMMOVABLE PROPERTY (IES) :
  • PLACE(S) WHERE LAND(S) OR BUILDING(S) IS/ARE SITUATEDPARTICULARS OF PROPERTY/ (IES)MARKET VALUE (RS.) 
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  • Liquid Assets
  • ParticularsDescriptionAmt. (Rs. )If encumbered to what extent 
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  • That I undertake and declare futher to notify to Amira Foods (India) ltd ., any change, whether by way of increase or diminution, in the assets / liablities as detailed above every year.

    That the Statements / declarations made in this Statement above are true to the best of my knowledge.

    Signature: _________________________ Signatory's Name: _______________________