info@samriddhifoundation.co.in

+91 8902269544

All fields are mendatory as mark *

Basic Details

State*

District*

Associate*

Upload Latest Photo

Retailer Details

Retailer Name*

Permanent Address

Police Station (Thana)

Axis Registered Mobile Numbers*

Airtel registered*

Owner e-Mail ID

CSP Center Details

CSP Center Location

Urban Rural

CSP Center Name (English)

Mobile

CSP E-Mail ID

CSP Contact Person's Name

CSP Contact Person's ( Contact )

CSP Center's Address (If Urban)*

CSP Center's Address (If Rural)*

CSP Center's Lat Long

CSP Bank a/c Details

Bank a/c Number

A/C Number

IFSC Code

Bank Name

Branch Name

Account Holder Name

If this CSP had already SAMRIDDHI FOUNDATION services

Services 1

Services 2