Dealer Fill-in Section
Merchant Registration NameChinese:English:Organization Code* 
Business License Number Nature of Business□ Limited Liability System □ Joint Stock System □ Private Non-Enterprise □ Individual Business □ Other (please specify)
Dealer Responsible Person Document Type□ ID Card □ Passport □ OtherDocument Number 
Store InformationRegistered Name

Same Merchant:

□ Yes □ No

(Please specify separately)

Yes
Business License NumberNo
Business NameSame Store Registered Name: □ Yes □ No (please specify) No
Business Scope 
Business Address  Province City (District) Street (Town) Neighborhood Committee (Village) NumberPostal Code 
Opening Date Year Month DayBusiness Hours : (a.m.)— : (p.m.)Business Area   M2
Number of EmployeesAbout   PeopleNumber of Business Floors  FloorsAverage Monthly Revenue Ten ThousandAbout Ten Thousand Yuan
Store Responsible Person PositionBoss

Contact Number

(Landline:  

  Mobile: )

Daily Contact Person

Same Store Responsible Person

□ Yes

□ No (please specify) Same Store

Name Position Contact Number 
Email Fax 
Settlement InformationAccount Name Clearing Account Number 
Bank Name Bank City Bank Contact Number 
Send Withdrawal Details Financial Contact Person Contact Number 
Merchant Signature Date Seal   
Our company's dedicated column
Name of investment specialist Salesperson code Tel Mobile EMAIL 
Promotion method□ Merchant actively applies
□ Actively contact merchants
On-site visit□ Yes □ NoVerify original documents□ Business license □ Organizational Chart code certificate
Tax proof documents
Promotion notesRegistered capitalTen thousand yuanMerchant establishment dateYear  Month  DayMerchant registered address 
Business environment□ Central business district □ Suburban business district □ Residential small business circle  □ Residential area □ Office area  □ Industrial area □ Other (please specify)
Store nature□ Street independent store □ Large shopping mall sales area □ Professional square shop space □ Office building □ Sales counter □ Other (please specify)
Sales method□ Wholesale □ Retail □ Both wholesale and retail □ OtherOperating channels□ Store □ Internet □ Phone/Fax □ Other     
Return policy□ Non-returnable □ Returnable (specific policy:                                              )
Assessor's name Assessor's code Assessment method□ Phone □ Internet □ On-site □ Other
Assessment notesSignature:         Date:
Person in chargeSignature:         Date:
Special applicationApplicant:                Date:      Year   Month   Day                       Authorized signatory:        Date: