Name*

Landline

Mobile*

Mobile Confirmation*

Email*

Email Confirmation*

State* --Select State-- ANDAMAN AND NICOBAR ISLANDS ANDHRA PRADESH ARUNACHAL PRADESH ASSAM BIHAR CHANDIGARH CHHATTISGARH DAMAN AND DIU DELHI DADRA AND NAGAR HAVELI GOA GUJARAT HIMACHAL PRADESH HARYANA JHARKHAND JAMMU AND KASHMIR KARNATAKA KERALA LAKSHADWEEP MAHARASHTRA MEGHALAYA MANIPUR MADHYA PRADESH MIZORAM NAGALAND ODISHA PUNJAB PUDUCHERRY RAJASTHAN SIKKIM TAMIL NADU TRIPURA TELANGANA UTTAR PRADESH UTTARAKHAND WEST BENGAL

District* --Select District--

NEAREST TOLL --Select Toll Plaza Name--

Distance From Toll (In Kms)

Are you willing to relocate at Toll*

Address for Tag Delivery*

Nearest Post Office*

PIN Code*

AADHAAR NUMBER*

AADHAAR IMAGE* Ex- Maximum upload size less than 30KB

PAN NUMBER*

PAN IMAGE* Ex- Maximum upload size less than 30KB

Bank Name* --Select Bank-- State Bank of India State Bank of Bikaner & Jaipur State Bank of Hyderabad State Bank of Travancore State Bank of Patiala State Bank of Mysore Allahabad Bank Andhra Bank Bank of Baroda Bank of India Bank of Maharastra Canara Bank Central Bank of India Corporation Bank Dena Bank IDBI Bank Indian Bank Indian Overseas Bank Oriental Bank of Commerce Punjab & Sind Bank Punjab National Bank Syndicate Bank UCO Bank United Bank of India Union Bank of India Vijaya Bank Baroda U.P Gramin Bank Baroda Gujarat Gramin Bank Sarva U.P Gramin Bank Punjab Gramin Bank Kerala Gramin Bank Himachal Gramin Bank Jharkhand State Co-operative Bank Kashi Gomti Gramin Bank Utkal Gramin Bank Vanchal Gramin Bank Purvanachal Bank Chhattisgarh Gramin Bank Baroda Rajasthan Gramin Bank Rajasthan Marudhara Gramin Bank HDFC Bank South Indian Bank Federal Bank Catholik Syrin Bank J&K Bank Baroda Rajasthan Kshetriya Gramin Bank Others

A/C Number*

Re-enter A/C Number*

IFSC Code*

Provided address details are correct and tags to be delivered at same address

Amount paid for tags will not refund in any circumstances

Verify your mobile number and Email ID, your SBI Log-in credentials will come on registered email id & mobile

As per the sale of tags commission to be paid in registered account on monthly basis