What is your name?

What is your mobile number?
We will use this information to contact you regarding participation in this program.

What is your email address?
We will use this information to contact you regarding participation in this program.

What is your age (in years)?

What is your educational background?
Below XII XII Pass or equivalent Graduate Degree Holder Post Graduate Degree Holder

Please provide information about your work experience so far?
Example: Sales Background OR student OR own medical store

How did you get to know about us?
Newspaper Ad Internet Ad From friend or family Others

If you get an Amazon Easy store, who will run it?
Myself OtherFamilyMember HiredStaff Others

How often do you shop online?
Weekly once 2-3 times in a month Monthly once 2-3times a year Never

In which location do you want to set up an Amazon Easy Store?
State
Andhra Pradesh Andaman and Nicobar Islands Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Dadar and Nagar Haveli Daman and Diu Delhi Lakshadweep Puducherry 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 Uttar Pradesh Uttarakhand West Bengal City

Enter the pin code of the location you wish to set up a store

Please provide communication address (with nearest landmark)
Example: Narappa Stores, D.No.3-10-9/1, Bommakanti Vari Street, Nidadavole, West Godavari Dist, Andhra Pradesh, 534101. Landmark: Next to LIC Office

Do you have other businesses?
Yes No

Who refer you to this page(enter email id of referer), if any