VENDOR CODE REQUISITION - FORM (Revised)

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REQUISITION FORM FOR SUPPLIER/SERVICE PROVIDER CODE (Please fill in Block Letter)

1.SUPPLIER/SERVICE PROVIDER NAME :…………………….……………………………………………………….

…………………………………………………………………………………………………………………………………...
2. SUPPLIER/SERVICE PROVIDER
Α. Head Office:
Address :…………………………………………………………………………………………………………………….....

……………..…………………………………………… Pin Code:………………………………………………….........

State :………………………………………………. Country :..………………………………………….…………..

Tel. No. :………………………………………………. Mobile No.:…....………………………………………………..

Fax No. :……….……………………………………… Email Id (Mandatory):..………………………………………

Contact Person:………………………………………... Designation:..…………………………………………………..

Β. Branch Office:
Address :…………………………………………………………………………………………………………………….....

……………..…………………………………………… Pin Code:………………………………………………….........

State :………………………………………………. Country :..………………………………………….…………..

Tel. No. :………………………………………………. Mobile No.:…....………………………………………………..

Fax No. :……….……………………………………… Email Id (Mandatory):..………………………………………

Contact Person:………………………………………... Designation:..…………………………………………………..

3.CATEGORY OF SUPPLIER: Please Tick the appropriate Category.(See Note 1 below)


α) Goods Remarks
β) Service Provider Remarks
χ) Sub-Contractor
δ) Transporter
ε) Assets

4. ZONE (Please Tick) : RO / EASTERN / DELHI / CHENNAI

5. GOODS AND SERVICE TAX IDENTIFICATION NO.(GSTIN) :.……………………………………………………....


(See Note 2 below)
6. MSMED REGISTRATION NO. & DATE. :.……………………………………………………....
(Copy of certificate enclosed)
VALIDITY PERIOD :Valid upto (Date) …………………...………………

7. PERMANENT ACCOUNT NO.(PAN) :……..………………………………………………....

8. DECLARATION IN PRESCRIBED FORMAT FOR GST :.……………………………………………………....


UNREGISTERED PARTY (See Note 3 below)

REQUISITIONED BY (BY SIMPLEX)

Name :…………………………………………………………… Designation :………………………………….

Contact No. :………………………………… Signature:………………………………… Date:…...…..……………….

Enclosures :..……………………………………………………………………………………………………..……………….

Remarks :……………………………………………………………………………………………………………………….

CHECKED BY APPROVED BY
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Note:
1. Please write type of Service Provider and short details of Goods in Remarks column in case of Category is Service Provider / Goods
respectively in Point No. 3 above.
2. In case of multi State Registration under GST, Details of all registrations are required in Point No. 8 above.
3. Copy of declaration on Stamp Paper of Rs 50/- duly not arised to be sent for Point no 8 above.

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