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Commission agent or reseller form
  1. Full Name*
    Please type your full name.
  2. Date of Birth*
    Birth Date Required
  3. Qualification
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  4. Current Occupation*



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  5. Company Name
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  6. Company Size*
    Please tell us how big is your company.
  7. Designation
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  8. Nature of Business
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  9. Resi. Address
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  10. Office Address
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  11. Zip Code
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  12. Tel
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  13. Mobile
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  14. FAX
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  15. E-mail*
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  16. Contact When
    Please select a date when we should contact you.
  17. Any Work Place



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  18. Planning to Promote Autonum Services in City/Teritory
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  19.  
  1. Please specify the work Force Including Technical/ Administrative / Marketing Staff. From above how many will be specifically utilized for Autonum's Promotion
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  2. How much business in terms of Revenue you are expected to generate
  3. For Repair Services
  4. 3 Months
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  5. 6 Months
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  6. 1 Year
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  7. For Selling Spares
  8. 3 Months
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  9. 6 Months
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  10. 1 Year
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  11. How Soon would you Like to Start Working
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  12. Brief summery in 150 to 200 words of your experience or which will help us in better decision
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  13. If any other information / Details you would like to Share:
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  14. If you have any printed leaflets/ catalogues / company profile you can send same to us speed post to our address or attach soft copy to this form.
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  15.   

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