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Application Form
"
*
" indicates required fields
1
Application Fields
2
Services Agreement
3
Nach online Registration Details
A. Customer Information
Customer Name
*
First Name
Last Name
Constitution
*
Individual
Proprietorship
Partnership
Pvt. Ltd
Limited
Limited Liability Partnership
Trust
Other
GST No.
*
Address
*
Pincode
*
City
*
State
*
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chhattisgarh
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttarakhand
Uttar Pradesh
West Bengal
Mobile No
*
Alternate No
B. Particulars for Individual / Proprietor / Key Promoters
First Name
*
First
Email Address
*
Mobile No
*
Alternate No
Emergency Contact Details
*
C. Product Details
Heartnet Device Type
*
HN Slim
HN Connect
HN Smart
HN Pro-Asaan
HN Prime
Heartnet Service
*
Yes
No
(In House Cardiologist)
Service Agreement Effective Date
*
DD dash MM dash YYYY
Agreement to be Made with
Company
Partnership Firm
Proprietorship Firm
Individual
Company Name
*
Company Registered Office Address
*
Partnership Firm Name
*
Partnership Firm Registered Office Address
*
Proprietorship Firm Name
*
Proprietorship Firm Registered Office Address
*
Proprietorship Firm Owner Name
*
Proprietorship Firm Owner's Father's Name
*
Individual Name
*
S/o or D/o
*
Residing at (address)
*
The Client Hereby Designates as
*
The Service Provider Hereby Designates as
*
Term & Termination
The Agreement shall Commence On
*
DD dash MM dash YYYY
Commencement date
Fee Schedule
Security Deposit (non-interest bearing) Fee as per Assan Console
*
One time installation fees + GST per Asaan Console
*
Monthly Subscription Fees + GST per Assan Console
*
as per Shedule 3 Slab No
*
OR
Monthly Subscription Fees + GST per Assan Console
*
for No. of Scans per month
*
Account Type
*
Current A/c
Savings A/c
Registration type
*
Net Banking
Adhaar Based Registration
Amount Limit
*
Customer Email ID
*
Phone No
*
Heartnet Center ID
*
Comments
This field is for validation purposes and should be left unchanged.
Group 4
support@heartnetindia.com
9740164242