FS-SIPEBAC ERA FORM

Shareholder / Investor / Partner / Entrepreneur / Businessman / Associate / Customer - 

Enrollment / Registration / Addmmission - FORM 

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Form No : _______________ 

Date : __ / __ / ___. 

S I P E B A C ' s     D E T A I L S 

I wish and want to enroll myself as : 

Shareholder / Investor / Partner / Entrepreneur / Businessman / Associate / Customer. 

SIPEBAC's FULL NAME : _________________________________________________________ 

FATHER's / HUSBAND's NAME : ___________________________________________________ 

MOTHER's NAME : ______________________________________________________________ 

SPOUSE's NAME : _______________________________________________________________ 

DATE OF BIRTH : __ / __ / ____ . AGE : ___ YRS. GENDER : M / F. NATIONALITY : Indian. 

SIPEBAC's CONTACT DETAILS : MOBILE : ____________ , ____________ , _____________ 

E-MAIL ID : _____________________________________________________________________ 

IDENTITY DETAILS : AADHAR NO : ______________________ PAN NO : __________________ 

EDUCATIONAL QUALIFICATIONS : 

S.N.  EXAM                             BOARD / UNIVERSITY    YEAR    SUBJECT / S          %      GRADE 

1]      Below S.S.C.                 ___________________    _____    ____________     _____  _______  

2]      S.S.C.                            ___________________     _____    ____________     _____  _______ 

3]      H.S.C.                            ___________________    ______   ____________     _____   _______ 

4]      GRADUATION              ___________________    ______    ____________    _____    _______ 

5]      POST-GRADUATION   ___________________    ______    ____________    ______  _______ 

6]      TECHNICAL                 ___________________    ______    ____________    ______   _______ 

7]      OTHERS                       ___________________    ______   _____________   ______   _______ 

EMPLOYMENT DETAILS : 

SERVICE / OCCUPATION : __________________________________________________________ 

DESIGNATION / POST : ____________________________________________________________ 

SIPEBAC's CORRUSPONDENCE ADDRESS : __________________________________________

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SIPEBAC's RESIDENCE ADDRESS : __________________________________________________ 

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SIPEBAC's PERMANENT ADDRESS : _________________________________________________ 

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SIPEBAC's OFFICE / WORK-PLACE ADDRESS : ________________________________________ 

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I agree to pay the Fees/ Charges / Investment Amount Rs. _______________________________ 

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Rs.________________________________________ Only. In favour of "FILICAMPS SERVICES" / 

MR. SHASHIKANT GOPAL GAVALE / MRS. SHARDA SHASHIKANT GAVALE. 

In Part / Full Payment by Cash / MO / IPO / Bank Deposit / DD / Cheque No : _________________, 

Dated : __ / __ /____ . Drawn on Bank : ________________________________________________, 

Branch : _______________________, Payable at : _______________________________________. 

To be paid in the Installments of EMIs : 01 / 02 / 03 / 04 / 05 / 06 / 12 Nos Each. 

SIGNATURE : 

Customer for Service : _____________________________________________________________ 

Associate of Authorized Service Centre : ______________________________________________ 

Businessman of Branch : ___________________________________________________________ 

Entrepreneur of Factory / Plant / Unit / Workshop : ______________________________________ 

Partner of Project / Venture : ________________________________________________________ 

Investor of Division / Group : ________________________________________________________