Yes Bank Registration Request
Type of Retailer रिटेलर विक्रेता के प्रकार	Existing Retailer New Retailer
Retailer Code रिटेलर कोड
Price List for New Retailt रिटेलर कोड	Rs 8000(Rs 5500-Get Oxigen GPRS Terminal & Web Vending + Rs 2500–Yes Bank Registration Fee) Rs 5500(Rs 3000-Get Oxigen SMS & Web Vending + Rs 2500–Yes Bank Registration Fee) Rs 3750(Rs 1250-Get Oxigen Web Vending+ Rs 2500–Yes Bank Registration Fee)
First Name of the Applicant* आवेदक का पहला नाम
Last Name of the Applicant* आवेदक का अंतिम नाम
Name of the Firm* फर्म का नाम
Is Firm Registered* पंजीकृत फर्म	YESNO
Date of Birth* जन्म तिथि
Address* पता
Area क्षेत्र
City* शहर	--Select City-- Agartala Agra Ahmedabad Aizawl Ajmer Akola Alapuzha Aligarh Allahabad Aluva Ambala Amritsar Anand Asansol Aurangabad Bangalore Belgaum Bharuch Bhatinda Bhavnagar Bhilai Bhopal Bhubaneshwar Bhuj Bikaner Bilaspur Bokaro Chandigarh Chengannur Chennai Coimbatore Cuddapah Cuttack Dadri Daman and Diu Darjeeling Davangere Dehradun Dhanbad Dharwad Dibrugarh Dimapur Dindugal Durg Durgapur Erode Faridabad Ferozpur Firozabad Gangtok Ghandinagar Ghaziabad Gorakhpur Gulbarga Guna Guntur Gurgaon Guwahati Gwalior Haldia Haldwani Hapur Hazira Hissar Hooghly Hoshiarpur Howrah Hubli Hyderabad Imphal Indore Jabalpur Jaipur Jalandhar Jalgaon Jammu Jamnagar Jamshedpur Jhansi Jodhpur Jorhat Kakinada Kandla Kannur Kanpur Karnal Katni Kharagpur Kochi Kodaikanal Kohima Kolhapur Kolkata Kollam Kota Kottayam Kovilpatti Kozhikode Kurnool Lucknow Ludhiana Madurai Mangalore Manipal Mapusa Margao Mathura Meerut Mehsana Mettupalyam Mirzapur Moradabad Mumbai Mysore Nadiad Nagercoil Nagpur Nainital Nashik Navsari Nazira Nellore New Delhi Nizamabad Noida Ooty Palakkad Panchkula Panipat Panjim Pathankot Patiala Patiala Patna Ponda Pondicherry Port Blair Pune Puri Raigarh Raipur Rajamundry Rajapalayam Rajkot Ranchi Ratlam Rewa Rishikesh Roorkee Rourkela Salem Sangor Saranpur Satna Secunderabad Shillong Shimla Shimoga Sibsagar Silchar Siliguri Silvasa Sivakasi Srinagar Surat Thane Thanjavur Thiruvananthapuram Tiruchchirapalli Tirunelveli Tirupati Tiruppur Tiruvalla Trissur Tumkur Tuticorin Udaipur Udupi Ujjain Vadodara Vapi Varanasi Vasco Vijayawada Virudhunagar Vishakapatnam Vrindavan Warangal Yamunanagar Others
District* जनपद	--Select District-- Adilabad Agra Ahmadabad Ahmadnagar Aizawl Ajmer Akola Alappuzha Aligarh Allahabad Almora Alwar Ambala Ambedaker Nagar Amravati Amreli Amritsar Anand Anantapur Anantnag Andamans Anugul Araria Ariyalur Auraiya Aurangabad Aurangabad Azamgarh Badgam Bagalkot Bageshwar Baghpat Bahraich Balaghat Balangir Baleshwar Ballia Balrampur Banas Kantha Banda Bangalore Bangalore Rural Banka Bankura Banswara Barabanki Baramula Baran Barddhaman Bareilly Bargarh Barmer Barpeta Barwani Bastar Basti Bathinda Baudh Begusarai Belgaum Bellary Betul Bhadrak Bhagalpur Bhandara Bharatpur Bharuch Bhavnagar Bhilwara Bhind Bhind Bhiwani Bhojpur Bhopal Bhopal Bid Bidar Bijapur Bijnor Bikaner Bilaspur Bilaspur Birbhum Bishnupur Bishnupur and Imphal West Bokaro Bongaigaon Budaun Bulandshahr Buldana Bundi Buxar Cachar Chamarajanagar Chamba Chamoli Champawat Champhai Chandauli Chandel Chandigarh Chandrapur Changlang Chatra Chennai Chhatarpur Chhindwara Chikmagalur Chitrakoot Chittaurgarh Chittoor Churu Coimbatore Cuddalore Cuddapah Cuttack Dadra and Nagar Haveli Dakshin Dinajpur Dakshina Kannada Daman Damoh Dantewada Darbhanga Darjiling Darjiling and Jalpaiguri Darrang Datia Dausa Davanagere Debagarh Dehradun Delhi Deoghar Deoria Dewas Dhalai Dhamtari Dhanbad Dhar Dharmapuri Dharwad Dhaulpur Dhemaji Dhenkanal Dhubri Dhule Dibang Valley Dibrugarh Dimapur Dindigul Dindori Diu Doda Dohad Dumka Dungarpur Durg East East Garo Hills East Godavari East Kameng East Khasi Hills East Nimar East Siang Ernakulam Erode Etah Etawah Faizabad Faridabad Faridkot Farrukhabad Fatehabad Fatehgarh Sahib Fatehpur Firozabad Firozpur Gadag Gadchiroli Gajapati Gandhinagar Ganganagar Ganjam Garhwa Garhwal Gautam Buddha Nagar Gaya Ghaziabad Ghazipur Giridih Goalpara Godda Golaghat Gonda Gondiya Gopalganj Gorakhpur Gulbarga Gumla Guna Guntur Gurdaspur Gurgaon Gwalior Hailakandi Hamirpur Hamirpur Hanumangarh Haora Harda Hardoi Hardwar Hassan Hathras Haveri Hazaribag Hingoli Hisar Hoshangabad Hoshiarpur Hugli Hyderabad and Rangareddi Idukki Imphal East Imphal West Imphal West and Imphal East Indore Jabalpur Jagatsinghapur Jaintia Hills Jaipur Jaisalmer Jajapur Jalandhar Jalaun Jalgaon Jalna Jalor Jalpaiguri Jammu Jamnagar Jamui Janjgir-Champa Jashpur Jaunpur Jehanabad Jhabua Jhajjar Jhalawar Jhansi Jharsuguda Jhunjhunun Jind Jodhpur Jorhat Junagadh Jyotiba Phule Nagar Kachchh Kaimur (Bhabua) Kaithal Kalahandi Kamrup Kancheepuram Kandhamal Kangra Kanker Kannauj Kanniyakumari Kannur Kanpur Kanpur Dehat Kanpur Nagar Kapurthala Karaikal Karauli Karbi Anglong Kargil Karimganj Karimnagar Karnal Kasaragod Kathua Katihar Katni Kaushambi Kawardha Kendrapara Kendujhar Khagaria Khammam Kheda Kheri Khordha Kishanganj Koch Bihar Kodagu Kodarma Kohima Kokrajhar Kolar Kolasib Kolhapur Kollam Koppal Koraput Korba Koriya Kota Kottayam Kozhikode Krishna Kullu Kupwara Kurnool Kurukshetra Kushinagar Lakhimpur Lakhisarai Lakshadweep Lalitpur Latur Leh (Ladakh) Lohardaga Lohit Lower Subansiri Lucknow Ludhiana Lunglei Madhepura Madhubani Madurai Maharajganj Mahasamund Mahbubnagar Mahe Mahendragarh Mahesana Mahoba Mainpuri Malappuram Maldah Malkangiri Mamit Mandi Mandla Mandsaur Mandya Mansa Marigaon Mathura Mau Mayurbhanj Medak Medinipur Meerut Mirzapur Moga Mokokchung Mon Moradabad Morena Muktsar Mumbai (Suburban) and Mumbai Munger Murshidabad Muzaffarnagar Muzaffarpur Mysore Nabarangapur Nadia Nagaon Nagapattinam Nagaur Nagpur Nainital Nalanda Nalbari Nalgonda Namakkal Nanded Nandurbar Narmada Narsimhapur Nashik Navsari Nawada Nawanshahr Nayagarh Neemuch Nellore Nizamabad North North Cachar Hills North Goa North Tripura North Twentyfour Parganas Nuapada Osmanabad Pakaur Palakkad Palamu Pali Panch Mahals Panchkula Panipat Panna Papum Pare Parbhani Pashchim Champaran Pashchimi Singhbhum Patan Pathanamthitta Patiala Patna Perambalur Phek Pilibhit Pithoragarh Pondicherry Porbandar Prakasam Pratapgarh Pudukkottai Pulwama Punch Pune Purba Champaran Purbi Singhbhum Puri Purnia Puruliya Rae Bareli Raichur Raigarh Raigarh Raipur Raisen Rajauri Rajgarh Rajkot Rajnandgaon Rajsamand Ramanathapuram Rampur Ranchi Rangareddi Ratlam Ratnagiri Rayagada Rewa Rewari Ri Bhoi Rohtak Rohtas Rudraprayag Rupnagar Sabar Kantha Sagar Saharanpur Saharsa Sahibganj Saiha Salem Samastipur Sambalpur Sangli Sangrur Sant Kabir Nagar Sant Ravidas Nagar Saran Satara Satna Sawai Madhopur Sehore Seoni Shahdol Shahjahanpur Shajapur Sheikhpura Sheohar Sheopur Shimla Shimoga Shivpuri Shrawasti Sibsagar Siddharthnagar Sidhi Sikar Sindhudurg Sirmaur Sirohi Sirsa Sitamarhi Sitapur Sivaganga Siwan Solan Solapur Sonapur Sonbhadra Sonipat Sonitpur South South South Garo Hills South Goa South Tripura South Twentyfour Parganas Srikakulam Srinagar Sultanpur Sundargarh Supaul Surat Surendranagar Surguja Tawang Tehri Garhwal Tehri Garhwal and Garhwal Thane Thanjavur The Nilgiris Theni Thiruvallur Thiruvananthapuram Thiruvarur Thoubal Thoubal and Imphal West Thrissur Tikamgarh Tinsukia Tirap Tiruchirappalli Tirunelveli Tiruvanamalai Tonk Toothukudi Tuensang Tumkur Udaipur Udham Singh Nagar Udhampur Udupi Ujjain Umaria Una Unnao Upper Subansiri Uttar Dinajpur Uttara Kannada Uttarkashi Vadodara Vaishali Valsad Varanasi Vellore Vidisha Viluppuram Virudhunagar Visakhapatnam Vizianagaram Warangal Wardha Washim Wayanad West West Garo Hills West Godavari West Kameng West Khasi Hills West Nimar West Siang West Tripura Wokha Yamunanagar Yanam Yavatmal Zunheboto Others
State* राज्य	--Select State-- Andaman & Nicobar Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhatisgarh Daman & Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu & Kashmir Jharkhand Karnataka Kerala Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Nagar Haveli Orissa Pondicherry Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttaranchal West Bengal
Pincode* पिन कोड
Telephone No. टेलीफोन नं
Mobile No* मोबाइल नंबर	+91
Alternate Mobile No वैकल्पिक मोबाइल नंबर	+91
E-mail Id* ईमेल आईडी
PAN No पैन नंबर
Voter ID मतदाता पहचान पत्र
Passport Number पासपोर्ट संख्या
Upload PAN Card(Scanned Copy) अपलोड पैन कार्ड (स्कैन कॉपी)
Verification Code सत्यापन कोड
Enter Verification Code सत्यापन कोड दर्ज करें
* Mandatory Field अनिवार्य फील्ड