Dealers Network Survey

Firm name *Legal status *Date of incorporation / start of business

Shop no.Floor / building

Road / landmark

Village / cityTaluka / tehsil / block

Post officePIN code

DistrictState

First name *Last name

Father's full name

Date of birthMarriage anniversary

DesignationWhatsApp number

Secondary phoneEmail

Same as proprietor / 1st partner / 1st director

First name *Last name

Father's full name

Date of birthMarriage anniversary

Designation

Secondary phoneEmail

WhatsApp number (OTP is sent here) *Telephone (landline)

Financial year *Enter amounts in

PesticidesFertilizers

SeedsOther

Total: ₹0

Interest levelNotesYour OneFarm Agro email (reps only)

Location (optional)

Records where the visit happened.

Signature — authorised signatory of the firm

Sign above with your finger.

Signature — OneFarm staff

Sign above with your finger.

An OTP will be sent to the WhatsApp number to confirm the visit.

This form is solely for gathering information and is not a binding contract, official business document, or legally incorporated entity.