TA Agent Application Form

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PERSONAL DETAILS

Name of Applicant
:
Father's Name :

Date Of Birth : D D M M Y Y Y Y Gender : Male Female Others

Marital Status : Single Married

Permanent Ac.No (PAN) : Aadhaar Number

Nationality : Indian Other

Residence Address :

City /Town : State :

PinCode : LandMark :

Mobile : Tel No :

Email ID :

Other Details

Shop Name :

Established Date : D D M M Y Y Y Y Shop License No.:

Shop Address :

Select The Documents and write ID No. Voter ID Driving license Electricity/Landline bill : Shop Reg No.*

Account Holder Name*

Bank Name

Account No* IFSC Code

DECLARATION:
I hereby declare that I have read and understood the terms & conditions provided with this form and I agree to all the terms and conditions as
listed on Transaction Analysts website. I hereby declare that the particulars given by me are correct and complete in all respect and the documents submitted
along with this application are genuine. I also hereby declare that I do not have any Criminal record. I hereby undertake to promptly inform Transaction
Analyst (India) Pvt. Ltd., Door No 4, Satyam Arcade, 1st Floor, 1st Phase, BTM Layout 2nd Stage, Bengaluru-560076 Karnataka of any changes in the
information provided herein above and agree and accept that Transaction Analysts (India) Pvt. Ltd. is not liable or responsible for any loses, cost , damages
arising out of any actions undertaken or activities performed by them on the basis of information provided by me as also due to my not intimating/ delay in
intimating such changes. I hereby agree to provide any additional information/ documentation that may be required by Transaction Analysts Pvt. Ltd, .I
hereby agree, to open a TA Agent wallet, along with the KYC documents submitted with this form, on my registered Mobile Number and will comply to the
terms and conditions as mention in TA Wallet.

Date : D D M M Y Y Y Y

Place : Seal or Stamp Name & Signature

Transaction Analysts (India) Pvt Ltd

Customer Care Number: +91 - 7899976084 | E-mail: support@transactionanalysts.com | Website: www.transactionanalysts.com