CUSTOMER DATA FORM
Red Mark Fields Are Mendatory
Name: Mobile Number
Father/Husband Name:  
Address:
State:
District:
Block/City
PinCode
Date of Birth: Profession
Name of your Bank Branch Account No.
E-Mail (If Any)  
Nominee Name Relationship
 
Unit Purchased through
With Customer No
Payment details of Rs 2250/- (if any)
Mode of payment
Issued through bank Demand draft No
Deposit in A/C No. 031001515081, ICICI Bank, Sigra Branch, Varanasi, U.P.,India On Dated
in the name of LAVA KUSH SINGH (Founder trustee & President of Natural Truth Mission, Trust)
GIVE TWO FEATURE'S COUSTOMER WHO DON'T BELIEVE IN THIS BUSINESS(Please fill in BLOCK LETTER)
Name:  
Father's/Husband Name:
Address:
State:
District:
Block/City
PinCode
 
Name:  
Father's/Husband Name:
Address:
State:
District :
Block/City
PinCode
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