Car Bonus Redemption

Request Form & Undertaking

A-1/175, Main Najafgarh Road, Janakpuri, New Delhi - 110058
Customer Care No.: 011-46277200 website : www.glazegalway.com, email : cc@glazegalway.com

Distributor Details
Name of the Distributor:
ID: Mobile No.: Date of Birth :
Level: Pan : Adhaar Card :
Franchisee Name :
Driving Licence No. : Residen"al Address :

Correspondence Address :

Car Details
Total Car Bonus Credit Points :
Model & Make of the Car :
Price of the Car (On Road) Rs. : Loan Amount against Car Rs. :
Name & the Address of the Bank from you are taking loan against Car :

Car Dealer Details

Dealer Name & Adress :

GSTIN of Dealer : Contact No. :

Dealer’s Bank A/c No. : IFSC Code :
Dealer’s Account Holder Name :
Bank Name :

Enclosures:
1.Performa Invoice for the Car
2.Copy of the Loan agreement (if any)
3.Financial Agreement between you and dealer
Undertaking
I have read the terms and condi"ons of “Car Bonus Redemp"on and Payment Policy” and agree to abide by them. I authorize
you to debit my Incen"ve account for the requisite number of Car Bonus Credit Points toward the purchase of above
men"oned Car. I further authorize you to make the payment of the redemp"on amount directly to the Car dealer.

Signature

Date :
 Car Bonus Claim
Rules and Regulations
A-1/175, Main Najafgarh Road, Janakpuri, New Delhi - 110058
Customer Care No.: 011-46277200 website : www.glazegalway.com, email : cc@glazegalway.com

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