1593252702.349 Dsa Empanelment - Form (Reworked)

Trufedu Budgetary Education Private Limited
DSA EMPANELMENT – REQUEST LETTER
To,
Block L, Embassy Tech Village Devarabisanahalli,
Outer Ring Road,
Bellandur Bengaluru,
KA 560103
Sub: Request for Empanelment as a Direct Selling Agent
Dear Sir,
I/We would like to apply for an empanelment with your organization as a DSA to
promote your services. I/We have enclosed herewith my/our profile sheet along
with necessary supporting documents. I/We also agree to execute the agreement
with your company after receiving the confirmation for the same.
Yours Faithfully,
Signature of the Applicant: _________________
Name of the Applicant: _______________________
Declaration: I/We hereby confirm that all information/documents submitted

by us along with the request letter are true and fair as on date of
application.
Encl:
1. Profile
2. PAN Card
3. Service Tax Registration Certificate / Exemption Certificate
4. Incorporation Documents (Applicable)
5. Address Proof
6. Identify Proof
7. Recent Photograph (In case of an Individual) to be pasted on the request form and signed across
8. Board Resolution (Applicable only in case of a Company)
DSA EMPANELMENT – FORM
Please provide all the information requested below. If additional space is required you may attach supplemental
sheets as per your need.
1. APPLICANT DETAILS / INFORMATION (IN BLOCK LETTERS)
A. CONTACT DETAILS
Name of the DSA

Mr. Ms. Mrs. M/s
Address
City Pin Code Area of Operation
Mobile Number Telephone Number / Fax Number
PAN Details Service Tax Number
E-Mail Id
B. TYPE OF BUSINESS (Tick One)
Individual Proprietorship Partnership Public Ltd. Private Ltd.
C. DATE & PLACE
Date of Birth/Incorporation Place of Birth/Incorporation
D. Number of Years in Current Business

Years
E. Name of Proprietors/Partner(s)/Director(s)&Key Contacts of the Applicant

Full Name Position / Title Since Mobile Number
F. Branches / Employees
Location Area Number of Branches Number of Employees
G. Industry Standing G. & Customer Base

Client / Company Name Since (Date) Products Managed Services Offered
H. Group Company Details, if any

Client / Company Name Since (Date) Products Managed Activities Undertaken
I. Indicate the Nature of any Relationships with TRUFEDU Affiliated with the DSA
Client / Company Name Since (Date) Products Managed Activities Undertaken
J. Banker Details
Bank Name
Full Address with Telephone Nos.
A/c Holder Name as appearing in Bank Statement
Bank A/c Number
MICR No.
2. OTHER DETAILS
A. Please specify the number of Permanent employees employed by the DSA

B. Does the DSA provide its employee's with ID Cards prominently displaying the name of
the employee, designation & name of the DSA on it?
Yes No
C. Does the DSA perform a background check on all employees before hiring?
Yes No
D. Does the DSA hire employees having industry experience?

Yes No
E. Does the DSA issue appointment letters to all new employees?

Yes No
F. Are the appointment letters signed & acknowledge by the employee?

Yes No
G. Does the DSA take resignation letters from employees leaving the organization, with reasons for
resignation?
Yes No
H. Do you subcontract any of your services?

Yes No
If Yes please list services below:

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
3. IS THE APPLICANT INVOLVED IN ANY LEGAL DISPUTE

Yes No
If Yes please provide the details below:

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4. DETAILS OF THE PERSON WHO WILL BE COORDINATING WITH TRUFEDU

Name of the Coordinator Designation Mobile Number Email Id
5. PHOTOGRAPH
I/We confirm that the details submitted by me/us are true and correct as on application date.
Signature and Stamp _______________________________________________________
Printed or typed name of Signatory ___________________________________________
Date _______________________Place _________________________________________
DOCUMENT CHECKLIST FOR DSA EMPANELMENT

SR.NO. CATEGORY VENDORS DOCUMENTS SOLE PARTNERSHIP PUBLIC /
PROPRIETORSHIP PRIVATE
LTD. CO.
1. Incorporation
Documents
Partnership Deed 
Memorandum & 
Article of Association
Certificate of 
Incorporation
Board Resolution 
2. Photo Id Passport
Proof Driving License
Voter’s Id Card Any one or two of these
Photo Credit Card
3. Photograph   
4. Address
Proof of
Copy of Latest Telephone
Bill
  
Vendor
Office
Copy of Latest Electricity
Bill
  
Premises Copy of Lease Deed   
Shops and Establishment
Certificate
  
Any Other Government
Issued Certificate
  
Pan Card   
Service Tax Certificate /
Exemption Certificate
  
FINANCIAL COUNSELLOR Recommendation Note:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Name of FINANCIAL COUNSELLOR: _____________________
Signature of FINANCIAL COUNSELLOR: ___________________________________________

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Trufedu Budgetary Education Private Limited

DSA EMPANELMENT – REQUEST LETTER

Sub: Request for Empanelment as a Direct Selling Agent

Signature of the Applicant: _________________

Name of the Applicant: _______________________

Declaration: I/We hereby confirm that all information/documents submitted

DSA EMPANELMENT – FORM

1. APPLICANT DETAILS / INFORMATION (IN BLOCK LETTERS)

Name of the DSA

City Pin Code Area of Operation

Mobile Number Telephone Number / Fax Number

PAN Details Service Tax Number

B. TYPE OF BUSINESS (Tick One)

Individual Proprietorship Partnership Public Ltd. Private Ltd.

C. DATE & PLACE

Date of Birth/Incorporation Place of Birth/Incorporation

D. Number of Years in Current Business

E. Name of Proprietors/Partner(s)/Director(s)&Key Contacts of the Applicant

G. Industry Standing G. & Customer Base

H. Group Company Details, if any

A. Please specify the number of Permanent employees employed by the DSA

D. Does the DSA hire employees having industry experience?

E. Does the DSA issue appointment letters to all new employees?

F. Are the appointment letters signed & acknowledge by the employee?

H. Do you subcontract any of your services?

If Yes please list services below:

3. IS THE APPLICANT INVOLVED IN ANY LEGAL DISPUTE

If Yes please provide the details below:

4. DETAILS OF THE PERSON WHO WILL BE COORDINATING WITH TRUFEDU

Signature and Stamp _______________________________________________________

Printed or typed name of Signatory ___________________________________________

Date _______________________Place _________________________________________

DOCUMENT CHECKLIST FOR DSA EMPANELMENT

FINANCIAL COUNSELLOR Recommendation Note:

Signature of FINANCIAL COUNSELLOR: ___________________________________________

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Date _Place ___________________