NITIRAJ ENGINEERS PVT. LTD.
BEHIND GURUDWARA, MUMBAI - AGRA ROAD, DHULE - 424 001(M.S) India
Tel: + 91 - 2562 - 239080, 239046, 239331; Fax: + 91 - 2562 239781
E-mail: dealer1@nitiraj.net
~ Assessment Form ~
Please fill below the following particulars & send it to the above address:
A)
Firm Details :
1) Name of the Firm/Company: .....................................................................................................
2) Address: .....................................................................................................................................
......................................................... Place: ....................................... Taluka: ..........................
Dist.: ................................................ State: ....................................... Pin Code: ......................
3) Status of the Constitution: Proprietary / Partnership / Private Ltd. / Public Limited
4) Year of establishment of firm: .....................................................................................................
5) Phone / Fax with S.T.D. Code: ...................................................Cell: …....................................
6) E-mail ID: ....................................................... 7) Website: ........................................................
7) Decision Makers Name: .............................................................................................................
Qualification: ........................................................................ Age: ...........................................
B)
Compulsory Information
1) Name the Carrier for Machine transportations is available at your place:.
………………..…………………………………………………………………………………………
2)
Name the Courier for small parcel is available at your place:
……………..……………………………………………………….……………………………………
3)
TIN No.: .........................................................................................................................………
4)
PAN No. : .................................................................................................................................
5)
Do you have Weights and Measures dealers/repairs Licenses? Yes / No.
If Yes, its Numbers: ……..........................................................................................................
C)
1) Current Line of Business
i) Products Currently Dealing in: ...............................................................................................
ii) Companies’ Currently dealing with: .......................................................................................
iii) Current Area Coverage: ......................................................................................................
iv) Market segment(s) currently catering to: ..............................................................................
2) Last 3 Years Turnover & Profit: ...........................................................................................................................................................
Year
Turnover (Rs)
Profit (Rs.)
...........................................................................................................................................................
2009 – 2010
2010 – 2011
2011 – 2012
…………………………………………………………………………………………………………………
Cont. Page 2...
...(2)...
3) Name of Bank(s) in which you operate your account(s): ……………………………………………
...
......................................................................................................................................................
4) Can invest how much for dealership of our products: Rs.: ..........................................................
D)
Current Setup
1) Built - up area of your commercial premises: ...............................................................................
2) Address of the commercial premises: ..........................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
3) How strategic is your location from business point of view:
i) Distance from Main Bus Stand: ...............................................................................................
ii) Distance from Railway Station: ................................................................................................
iii) Distance from Central Market Place: ........................................................................................
iv) No. of sales staff currently employed: ......................................................................................
E)
District(s) Interested in For Dealership: ........................................................................................
...........................................................................................................................................................
F)
Any other Information: ...................................................................................................................
...........................................................................................................................................................
G)
...........................................................................................................................................................
Why do you think you can deal in our PHOENIX ® Electronic Weighing Scales & Systems?
...........................................................................................................................................................
...........................................................................................................................................................
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...........................................................................................................................................................
Date
:
/
/ 20
Place : .................................
Name of Authorized Signatory: .................................................
For: ...............................................................................................
Signature: ....................................................................................

Please attach the following documents as annexure with the filled Assessment Form.
1) Duly filled Assessment Form.
2) Copy of VAT TIN Registration no.
3) Copy of Weight and Measurement dealers and repairers license.
4) Copy of PAN Card.
5) Copy of Address proof.
6) Cheque in favor of Nitiraj Engineers Pvt. Ltd.: The payment towards liability against form 'C ’.