Company Name

Type of Company

Authorize Person Name

Designation

Email

Company Logo

Reg Office room/flat no

Reg Office Building/House name

Reg Office Road name

Reg Office Area/locality

Reg Office Pincode

Correspondence room/flat no

Correspondence Building/House name

Correspondence office Road name

Correspondence office Area/locality

Correspondence Office Pincode

Landline (mention city code followed by telephone. for eg. 912266331234)

Alternative Landline (mention city code followed by telephone. for eg. 912266331234)

Mobile Number (mention only 10 digit N0. for eg. 9820098200)

Alternative Mobile Number (mention only 10 digit N0. for eg. 9820098200)

Alternative Email Id

Fax Number

Website Address ( for eg. http://www.bchaa.com )

Numbers of Employee with
Custom passes

Old CHA No
(Registration Number given by local custom House)

New CHA PAN Based No Eg : AACCN3255BCH321

GST No.

MBPT VALIDITY DATE

Membership Registration Form

Company Details