Registration

Application Form

Basic Details

I am at least 18 years old and a Citizen of India

By clicking "become a pueraria distributor" you are agreeing to the Privacy & Security and the Terms & Conditions of the Pueraria Ayurveda website in effect at the time of use.

Documentation

In order to make your registration experience seamless, Please make sure you are ready with the following documents:

Bank Account Details
Bank proof (for Upload)
ID proof (for Upload)
Address proof (for Upload)

Contact Details

Mobile No * :

Email Id :

Personal Details

Name *:

Upload Photo *:

You can upload only .jpeg,.jpg file format and file size within 5 MB

Date of Birth *:

Gender *:

Marital Status *:

Spouse Name:

*:

Blood Group :

Occupation *:

Qualification :

Address Details

Flat No./ Room No. / Street / Village *:

Pin *:

Post *:

P.S *:

District *:

City :

State* :

Country :

Account Details

Bank Name *:

IFSC *:

Bank Branch Name *:

Account No. *:

Type Of Account *:

PAN

Document

*:

Frontside
Backside (If any)
You can upload only .pdf,.jpeg,.jpg file format and file size within 5 MB

PAN*:

You can upload only .pdf,.jpeg,.jpg file format and file size within 5 MB

Upload Bank Proof *:

You can upload only .pdf,.jpeg,.jpg file format and file size within 5 MB

Nominee (above 18 years of age Mandatory)

Name :

Date Of Birth :

Age :

Relation to Nominee :

Address :

DECLARATION

I/We here by verify that I/We have requested the above mentioned change in respect my/ our distributorship and agree to remain bound by the Pueraria AyurvedaDistributorship agreement as amended from time.

I/We understand that the information change will be effective only after receipt of this form and supporting documents by Pueraria Ayurveda

Any amount payable to the distributor as Commission / Bonus, and any other payment by the company is inclusive of all taxes, by whatever

name called, including GST, Income Tax, and other taxes. These taxes are payable by the distributor as and when they are required to be paid as per prevailing laws.

I have read and agree to the RULES AND REGULATION

Application No. :

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