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 *
IFSC Code / SWIFT *
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?
YesNo
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.

Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon Sign up for our Email Newsletter
For Email Marketing you can trust
Privacy Policy | Cancellation & Refund Policy | Shipping & Delivery | Disclaimer | Terms & Conditions | Sitemap
© 2011 Industrial Research Corporation | Powered by SYNAMEN