Affiliate / Reseller Registration Form
Individual, Firm or Company Name *
Date Of Birth (For Individuals)
Email ID *
Password *
Confirm password *
TIN No (If Applicable)
CST No. (If Applicable)
Residence / Office Address *
Country *
State *
City *
Pincode *
Telephone *
Mobile *
Present Business or Profession *
Bank Name *
Branch *
Account Number *
Do you have a computer?
Yes No
If Yes
Laptop Desktop
How did you hear about the Bril Affiliate/Reseller Program?(If referred by another reseller please mention name,contact number and reseller number
(if available)
Do you have any prior direct sales experience?
If Yes please mention company and product category

Not readable? Change text
Please enter the characters displayed
I have read the Terms & Conditions and agree to it.

You can also download the Reseller Application form and submit it offline at our Head Office. Please click here to download the form.