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New Channel Registration Form

Click here to download Excel format of the registration form (please fill and send us to info@netxsecuritysolutions.com)


Personal Details
Company Name Correspondance Address
Phone Number Postal Code
Fax City
Website Country
Head Office Address Registered Office Address
Company Data
Present Legal Status Company Premises
No. of employees Active customers
Company Description Industry to which applicant belongs
Date of incorporation Company PAN No.
GST No. PAN No.
Turnover NeTXGATE Product (If any) Correspondance Address
Contact Information
Name Designation
Phone Email
Director’s Details
Name Address
Email Phone
Bank Details
Bank Name Bank Address
MICR Code Account Number
Reference Customers-1
Name of Organization Contact Person
Phone Email
Designation Other details if any
Reference Customers-2
Name of Organization Contact Person
Phone Email
Designation Other details if any