REGISTRATION FORM To be filled by Online Agents members requesting for Online

Booking throughwww.irctc.co.in. / Web services Portal

[Soft Copy] * Mandatory

Company Name * NAME SERVICES

    Person Representing Company

First Name * RAVI

Middle Name KIRAN

Last Name * AKURATI

Date Of Birth * 05-05-1982

Office Address * as verified by Deptt of POST D.No.21-11-151, MAIN ROAD PERALA, NEAR ANDHRA BANK, PRAKASAM DISTRICT,

City * CHIRALA

State * AP

Pincode *(to be verified by the Principal Agent 523157

Country* INDIA

Phone Number*/Mobile No 9603405883

Fax Number

Email Id * info@onlineagents.in

Verified PAN No. AKMPxxx278N

Declaration of Sub agent obtained (Soft copy available with the Principal Agent).

Willing to be registered with M/s_________________

He is not registered with any other Principal Agent

SIGNATURE