DHAN BIO NATURALS 10/5,Sivanandham Colony, Korattur, Chennai . 600080. Tamilnadu, India Web: www. dhanbionaturals.com - email: dhanbionaturals@gmail.com I N D E P E N D E N T D I S T R I B U TO R A P P L I C AT I O N F O R M NAME Status Individual Entity Gender Male Female Affix Photo Tg S/o / D/o / W/o Income Tax Permanent Account No. Date of Birth D D M M Y Y Y Y ADDRESS Line 1 Line 2 Line 3 City Pincode Country State Phone E-mail Mobile Nominee Age Relationship Placement Placed under Independent Distributor Code Sponsor code Name Name Placed under Team Winno Activa Name of account holder as per bank records IFS code Account No. Bank & Branch Declaration by the applicant: I / we _______________________________have read and understood the Definintions, General Policies, Procedures, Terms and conditions of independent Distributorship printed overleaf of the application form and I declare that I am fully aware and conversant with the same. I hereby apply to join in your company as an Independent Distributor. I have applied to become an Idependent Distributor out of my free will and choice and hereby agree to abide by the terms and condtions of the company in force. Also I understand and agree that I will be bound by any amendments, notifications published / circulated time to time. Further I declare that I have signed Independent Distributor application personally and all the particulars given above are true to the best of my knowledge and the signature affixed here in this applicationis my authentic signature and I undertake to intimate the company any modifications to that. I am aware that any false information would result in termination of my Distributorship without any benefit whatsoever. Signed at on D D M M Y For office use only Code allotted Remarks Y Y Y Applicant’s Signature