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: NIL 1. Submitted for (tick whichever is applicable): (a) Issue ____ (b) Renewal ______ (c) Restoration ______


(a) Particulars of Sl. "o.

ertificate of Practice issued ! surrendered! ancelled earlier of Practice #ate of issue of P NA #ate of surrender ! ancellation of P

ertificate "o. NA


$. i. I state that I shall be en%a%ed in the profession of ompan& Secretar& onl& on whole'time basis and not in an& other profession( business( occupation or emplo&ment. I am not enrolled as an )dvocate on the rolls of an& *ar ouncil and do not hold certificate of practice from an& professional bod& includin% I )I and the I +)I. I state that as and when I cease to be in practice( I shall dul& inform the ouncil and shall surrender forthwith the certificate of practice as re,uired b& the ompan& Secretaries )ct( 1-./( and the re%ulations made thereunder( as amended from time to time. I hereb& undertake that( I shall adhere to the mandator& ceilin% of not more than ei%ht& companies in a%%re%ate in a calendar &ear in terms of the Guidelines for Issuing Compliance Certificate and Signing of Annual Return issued b& the Institute on 01th "ovember( 0//1. I state that I have issued ! did not issue ... 2 2 advertisements durin% the &ear 0/2 ' 2 in accordance with the Guidelines for Advertisement by Company Secretary in Practice issued b& the Institute3. I state that I issued 2 2 2 orporate 4overnance compliance certificates under listin% a%reement durin% the &ear 0/2 2 ' 2 3 lause 5- of the




v. vi.

I state that I have ! have not undertaken 2 2 2 )udits under Section 66) of the Securities and 78chan%e *oard of India (#epositories and Participants) Re%ulations( 1--9 durin% the &ear 0/2 ' 2 3

vii. I state that I have ! have not maintained a re%ister of attestation!certification services rendered b& me!m& firm in accordance with the Guidelines for Requirement of Maintenance of a Register of Attestation/Certification Services Rendered by Practising Company Secretary/Firm of Practising Company Secretaries issued b& the Institute. 3 5. 6. I send herewith *ank draft drawn on 2 2 2 2 2 2 *ank 2 2 2 2 2 *ranch bearin% "o. 2 2 2 2 for Rs 6//!' towards annual certificate of practice fee for the &ear endin% $1st :arch 0/1/ I further declare that the particulars furnished above are true and correct.

;ours faithfull&( (Si%nature) Place:

7ncl. #ate: ____________________________________________________________________________________________ 3 )pplicable in case renewal or restoration of ertificate of Practice