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P Nagar 4th Phase. CLIENT REGISTRATION FORM BRANCH/AUTHORIZED PERSON CODE: BRANCH / AUTHORIZED PERSON NAME: INTRODUCER/CODE: CLIENT CODE: CLIENT NAME: 1 sign wherever you see . In case you are not satisfied with the response.com or Phone No. Bangalore . Opp.com Compliance Officer Details CEO Details Name: Venu Madhav Name: Nithin Kamath Email ID: compliance@zerodha.com or call 080-40402020. Clarence Public School.zerodha.P Nagar 4th Phase. Clarence Public School.com | Website: www. Opp.560078 Phone: +91-80-40402020 Fax: +91-80-41682349 Email: india@zerodha.: 022-66406084. Zerodha Commodities Private Limited Membership Details: Exchange Registration No.com | Website: www.zerodha. Bangalore .: 022-67318888. FMC Unique Membership Code (UMC) MCX 46025 MCX/TM/CORP/1945 NCDEX 1138 NCDEX/TM/CORP/1113 Registered Office Address Zerodha Commodities Private Limited #153/154. 4th Cross Dollars Colony.com Email ID: ceo@zerodha. MCX at grievance@mcxindia. J. J. please contact the concerned exchanges.com or Phone No. NCDEX at askus@ncdex.560078 Phone: +91-80-40402020 Fax : +91-80-41682349 Email: india@zerodha.com Phone No: +91-80-40402020 Phone No: +91-80-40402020 For any grievance/dispute please contact Zerodha Commodities Private Limited at the above mentioned address or email complaints@zerodha. 4th Cross Dollars Colony.com Correspondence Address Zerodha Commodities Private Limited #153/154.

Dos and Don’ts for the Document detailing dos and don’ts for trading on exchange for 4 the education of the investors.Document captures the basic information about 1 the constituent and an instruction/check list. and Dos & Don’ts 10 10 Annexure-P Additional Rights & Obligations Annexure 11 Annexure-Q Letter of Authority 11 2 sign wherever you see . Authorized Person 3 Members. 4 Application Form) for Individual Uniform Risk Disclosure Document detailing risks associated with dealing in the 2 commodities market. Annexure Investors Document detailing the rate/amount of brokerage and other 5 Tariff Sheet charges levied on the client for trading on the Commodity 8 Exchange(s) VOLUNTARY DOCUMENTS AS PROVIDED BY THE MEMBER 7 Appendix-A Electronic Contract Note [ECN] Declaration 9 8 Annexure-N Disclosure Information 10 9 Annexure-O Receipt of KYC. Annexure Document (RDD) Rights and Obligations of Document stating the Rights & Obligations of Member. Stock ZERODHA COMMODITIES PRIVATE LIMITED SET OF ACCOUNT OPENING DOCUMENTS S. RDD. Authorized Persons and Client for trading on exchanges (Including additional rights & Annexure and Client obligations in case of Internet/wireless technology based trading). Name of the Document Brief Significance of the Document Page No MANDATORY DOCUMENTS AS PRESCRIBED BY SEBI & EXCHANGES KYC (Account Opening KYC Form . Rights & Obligations.Dr. No.

4. Judge. Copy of cancelled cheque leaf/ pass book/bank statement specifying name of the constituent. Identity card / document with applicant's Photo. Form need to be initialized by all the authorized signatories. their (which are duly notarized and / or apostilled or consularised) that gives the registered passport copy should be given. 1956. List of people authorized to attest the documents: Public Sector Undertakings. Name & address of the applicant mentioned on the KYC form. 5.List of documents admissible as Proof of Address: 2. Additional documents in case of trading in derivatives segments . Public Sector 6. Unique Identification Number (UID) (Aadhaar)/ Passport/ Voter ID card/ Driving license. Proof of address issued by any of the following: Bank Managers of Scheduled 4. Scheduled Commercial Banks. Court receiver 11. senior executives of state owned corporations. 9. In case of NRIs. C. Colleges affiliated to Universities. such claims to be collected. VCFs. namely. (Continuous Discharge Certificate) is to be submitted. Demat master or recent holding statement issued by DP bearing name of the client.) Banks registered in India. IMPORTANT POINTS: 1. Magistrate. Investors residing in the state of Sikkim. Court Magistrate. b.. Identity card/document with address. UN entities / multilateral agencies exempt from paying taxes / filing tax returns in India. then proofs for both have to be submitted. Development Corporations. senior Government/judicial/ military officers. 7. Mariner's declaration or certified copy of CDC 8. For non-individuals: a.) photocopy of the School Leaving Certificate/Mark sheet issued by Higher Secondary 1.g. ICSI. In case of non-resident clients. ICWAI. 5. documents as per risk management policy of the stock broker need to be provided by the client from time to time. securities on behalf of company/firm/others. Court. Central/State Government and its Departments. 3. Public Financial Institutions. List of documents admissible as Proof of Identity: 5. employees at the stock broker's local office. Heads of States or of 2. Utility bills like Telephone Bill (only land line). (allowed to trade subject to RBI and FEMA affiliated to Universities and Professional Bodies such as ICAI. Further. Gazetted Officer. to their Members. mandatory. Copy of Board Resolution or declaration (on the letterhead) naming the persons authorized to deal in securities on behalf of company/others & their specimen signatures. Copy of Form 16 Net worth certificate Copy of demat account holding statement. Undertakings. In case the original of any document is not produced for verification. Indian Embassy /Consulate General in the country where the client resides are permitted to attest the documents. considering the infeasibility of carrying out 'In-person' verification of the non-resident clients by the stock broker's staff. Scheduled Commercial Banks. In case of transactions undertaken on behalf of Central Government and /or State Board/Passport of Minor/Birth Certificate must be provided. Manager of a Scheduled Commercial / Co-operative ICWAI. Statutory/ Regulatory Authorities. Power of Attorney given by FII / sub-account to the Custodians 8. For non-residents and foreign nationals. copy). address should be taken. copy of passport/PIO Card/OCI Card and overseas address proof is etc. Electricity bill or Gas bill .Not more than 3 2.. If correspondence & permanent address are different. etc. shall verify the PAN card details with the original PAN card and provide duly certified 3. The proof of address in the name of the spouse may be accepted. Notary Public.a. SIP of Mutual Funds up to Rs 50.g. MICR Code or/ and IFSC Code of the bank should be submitted. E. Bar Council guidelines). e. Scheduled Commercial Banks. In case of Merchant Navy NRI's.Not more than 3 months old. Stock broker has an option of doing 'in-person' verification through web camera at the branch office of the stock broker/sub-broker's office. 4.. Governments. For foreign entities. required. Gazetted Officer / Notary Public / Elected representatives to the Legislative Assembly/ Parliament / Documents issued by any Govt. Official liquidator.illustrative list: Copy of ITR Acknowledgement Copy of Annual Accounts In case of salary income . Bank Account Statement/Passbook -. for a minor. Indian Embassy / Consulate General in the country where the client resides may be permitted. issued by any of the following: Central/State Government and its departments. then the copies should be properly attested by entities 3. Colleges 7. Professional Bodies such as ICAI. then translation into English is respect of their own accounts. authorized for attesting the documents. Local Banker. Self declaration with relevant supporting documents.000/.p. For opening an account with Depository participant or Mutual Fund. Notary Public. overseas can do in-person verification. For FII / sub account. In case of institutional clients. Proof of Identity (POI): . State Industrial 1. 3 . 2. issued by any of the following: copies of such verified PAN details to the intermediary. 6. and in the absence of DIN no. Bar Council etc.Salary Slip. accompanied by originals for verification. Public Financial Institutions. important political party officials. MFs. FIIs. attestation of KYC documents by Notary Public. F. Self attested copy of PAN card is mandatory for all clients. as per the below mentioned list. Government and by officials appointed by Courts e. FVCIs. Politically Exposed Persons (PEP) are defined as individuals who are or have been etc. If any proof of identity or address is in a foreign language. Custodians 2. *In respect of other clients. Sole proprietor must make the application in his individual name & capacity. Self-declaration by High Court and Supreme Court judges. authorized officials of overseas branches of Scheduled Commercial (*Documents having an expiry date should be valid on the date of submission. should match with the Commercial Banks / Scheduled Co-Operative Bank / Multinational Foreign Banks / documentary proof submitted. and Credit cards/Debit cards issued Bank or Multinational Foreign Banks (Name. Multilateral and Bilateral Development Financial Institutions. Insurance Companies registered with IRDA and Public Financial Institution as defined under section 4A of the Companies Act. Passport/ Voters Identity Card/ Ration Card/ Registered Lease or Sale Agreement of /Partners /Karta /Trustees and whole time directors and persons authorized to deal in Residence/ Driving License. Bank account statement for last 6 months Any other relevant documents substantiating ownership of Assets. Designation & Seal should be affixed on the by Banks. Judge. G. CIN is optional.INSTRUCTIONS / CHECKLIST FOR FILLING KYC FORM A. H. Copies of all the documents submitted by the applicant should be self-attested and months old. or Statutory Authority. giving the new address in 3. entrusted with prominent public functions in a foreign country. B. PAN card with photograph. ICSI. for the directors. senior politicians. to their Members. For Individuals: a. Proof of Address (POA): . D. b. Statutory / Regulatory Authorities. including Promoters 1. Exemptions/clarifications to PAN (*Sufficient documentary evidence in support of 10. 1.

Gender * Male Female 3b. Specify Proof of Identity Submitted Pan Card Other (Please Specify) _______________________________ B ADDRESS DETAILS 1. PAN A W A P A 9 3 9 6 F 5b. Father's/Spouse's Name F1 3a. Date : D D M M Y Y Y Y F2 Client Signature FOR OFFICE USE ONLY In Person Verification (IPV) Details: Name of the Person who has done the IPV: __________________________________________________ Designation: ____________________________________ Employee ID: __________________________ Name of the Organization: ZERODHA Date of the IPV: D D M M Y Y Y Y Signature of the Person who has done the IPV Seal/Stamp of the Intermediary Originals Verified and Self-Attested Document Copies Received Date Signature of the Authorized Signatory 4 Sign wherever you see . Residence/Correspondence Address HOUSE NO RH 19 NEAR WAREHOUSE GAUSHALA PARA RAIGARH City/Town/Village RAIGARH Pin Code 496001 State CHHATTISGARH Country INDIA 2. Nationality Indian Other (Please Specify)_______________________________ 4b. I am aware that I may be held liable for it. if any 6.Know Your Client (KYC) Application Form . Specify the Proof of Address Submitted for Residence / Correspondence Address: _____________________________ 3. Contact Details Telephone (Office) Fax Telephone (Residence) Mobile No 7747995980 Email ID mashahir.com 4. Marital Status Single Married 3c. Status Resident Individual Non Resident Foreign National 5a. Name of the Applicant Please affix your recent passport size MASHAHIR AHMED photograph and sign across it 2.ahmed@gmail. In case any of the above information is found to be false or untrue or misleading or misrepresenting. Permanent Address HOUSE NO RH 19 NEAR WAREHOUSE GAUSHALA PARA RAIGARH City/Town/Village RAIGARH Pin Code 496001 State CHHATTISGARH Country INDIA DECLARATION I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein.for Individuals New Change Request (Please tick ✔ the appropriate box) Please fill this form in English and BLOCK Letters (Please tick the box on the left margin of the appropriate row where CHANGE/CORRECTION is required and provide the details in the corresponding window) A IDENTITY DETAILS Photograph 1. Date of Birth 2D 4D M 0 4M Y1 Y9 Y8 Y9 4a. immediately. Unique Identification Number (UID) / Aadhar.

Name of the National Date of Consent for trading on concerned Exchange Signature of the Client No. MCX F3 1. Central Sales Tax Validity Date I. E. VAT DETAILS (As applicable. SALES TAX REGISTRATION DETAILS (As applicable. Validity Date Local VAT (Details of all states where registered) 5 sign wherever you see . Validity Date Local Sales Tax (Details of all states where registered) Registration No. Sr. State wise) State Registration No. NCDEX F3 G. if available Depository Participant Depository Name (NSDL/CDSL) Beneficiary Name DP ID Beneficiary ID (BO ID) Name Note: Provide a copy of either Demat Master or a recent holding statement issued by DP bearing name of the client. The Exchange not chosen should be struck off by the client.) as on (Date) (Net worth should not be older than 1 year) D D M M Y Y Occupation Private Sector Public Sector Government Service Farmer (Please tick any one and give brief details) Business Professional * Others (Specify) PRIVATE SECTOR Please tick as Politically Exposed Person (PEP) Related to a Politically Exposed Person applicable Not a Politically Exposed Person Not related to a Politically Exposed Person D. Commodity Exchanges # 1. MICR code or/and IFSC Code of the bank. State wise) State Registration No. F. OTHER DETAILS Gross Annual Income Details Below 1 Lac 1-5 Lac 5-10 Lac 10-25 Lac > 25 Lacs or Net worth (Rs. IFSC Code Saving HDFC BANK SUNDER NAGAR 50100112319 Current BRANCH GROUND 269 Others FLOOR Note: ORBIT Provide a copy of cancelled chequeCOMPLEX leaf/ pass book/ bank statement specifying name of the client. DEPOSITORY ACCOUNT(S) DETAILS. TRADING PREFERENCES Note: Please sign in the relevant boxes against the Exchange with which you wish to trade. INVESTMENT/TRADING EXPRIENCE Investment Experience No prior experience Years in Commodities Years in other investment related fields H. BANK ACCOUNT(S) DETAILS Bank Name Branch Address Bank Account # Account Type MICR No.C.

provide details of all in a separate sheet containing all the information as mentioned below: Member’s/Authorized Person (AP)’s Name Exchange Exchange Registration No Concerned Member’s Name with whom AP is registered Registered Office Address Phone Fax Website Email Client Code Details of disputes/dues pending from/ to such Member/ AP: L. details of guardian: Name of Guardian Signature of Guardian Address & Ph. DEALINGS THROUGH OTHER MEMBERS If client is dealing through any other member. PAST REGULATORY ACTIONS Details of any action/proceedings initiated/pending/taken by FMC/ SEBI/ Stock Exchange/ Commodity Exchange/ any other Authority against the client during the last 3 years: K. No. No. provide the following details (in case dealing with multiple members. of Witness 6 sign wherever you see . INTRODUCER DETAILS (Optional) Name of Introducer Status of the Introducer Authorized Person Existing Client Others Address & Ph. of Introducer Introducer’s Signature Introducer Code M. of Guardian WITNESSES (Only applicable in case the account holder has made nomination) Name of Witness 1 Signature of Witness Address & Ph.J. No. No. ADDITIONAL DETAILS Whether you wish to receive communication from member in electronic form on your Email ID Yes No {If Yes then please fill in Appendix-A} N. NOMINATION DETAILS I/We do not wish to nominate I/We wish to nominate Name of Nominee Relationship with Nominee PAN of Nominee DOB of Nominee Address & Ph. of Witness Name of Witness 2 Signature of Witness Address & Ph. of Nominee If Nominee is a minor. No.

I am/we are aware that I/we may be held liable for it. DECLARATION 1. In case any of the above information is found to be false or untrue or misleading or misrepresenting. I/We confirm having read/been explained and understood the contents of the tariff sheet and all voluntary/non. I/We do hereby agree to be bound by such provisions as outlined in these documents. I/We also undertake that any change in the 'Rights and Obligations' and RDD would be made available on my/our website.mandatory documents. I/We further confirm having read and understood the contents of the 'Rights and Obligations' document(s). 3. RDD. I/We have also been informed that the standard set of documents has been displayed for Information on Member's designated website. if any. 'Risk Disclosure Document' and 'Dos and Don’ts'. immediately. I/We undertake that any change in the tariff sheet and all the voluntary/non- mandatory documents would be duly intimated to the clients. I/We have also made the client aware of 'Rights and Obligations' document (s). I/We have given/sent him a copy of all the KYC documents. Date: ________________________________________ Place: F4 FOR OFFICE USE ONLY UCC Code allotted to the Client Documents verified with Originals Name of the Employee Employee Code Designation of the Employee Date of Verification Signature of Employee I/We undertake that we have made the client aware of tariff sheet and all the voluntary/non-mandatory documents. for the information of the clients. 2. if any. I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I/we undertake to inform you of any change therein. Date: _____________________________________________ Signature of the Authorized Signatory Seal/Stamp of the Member 7 sign wherever you see . 'Dos and Don’ts' and Guidance Note.

SEBI Charges of Rs. ZERODHA TARIFF SHEET ZERODHA COMMODITIES PRIVATE LIMITED #153/154. Client ID: _______________________ Charge Head Brokerage / Charges Commodity Futures 0. Opp. Education Cess and Higher Education Cess 5. 4th Cross Dollars Colony. Clarence Public School. 20 per contract note plus courier charges In addition to brokerage. Commodity Transaction Tax as per the Government of India 6.560078 Charges for Zerodha Trading Services on MCX/NCDEX: I/We agree to pay the charges as per following charge structure for our Trading account with Zerodha effective from the time of account opening. Turnover Charges 2. Bangalore .com/charge-list ______________________________________ F5 8 sign wherever you see . Service Tax 3. whichever is lower Clients who opt to receive physical contract notes will be charged Rs. the following statutory charges will also be levied for trading Schedule of Charges: 1. Stamp Duty: State-wise stamp duty as applicable will be levied 4.01% of turnover or Rs 20 per executed order.P Nagar 4th Phase. J. 20 per crore on Turnover  Detailed explanation of the Schedule of Charges is available online at https://zerodha.

A To. • I am aware that this declaration form should be in English or in any other Indian language known to me.) Client Name: ________________________________________________________________________ MASHAHIR AHMED Unique Client Code: ______________________________ PAN: __________________________________ AWAPA9396F HOUSE NO RH 19 NEAR WAREHOUSE GAUSHALA PARA RAIGARH RAIGARH Address: ________________________________________________________________________ ________________________________________________________________________ CHHATTISGARH 496001 INDIA Signature of Client F6 Date: ____________________ Place:__________________________ For Office Use Only Verification of the client signature done by _________________________________________________________ Name of the designated officer of the Member Signature: ________________________________________________ Date: __________________________ 9 sign wherever you see sign wherever you see . MASHAHIR AHMED _________________________________________________________________________________________________________ a client with Member M/s. • My email ID is _______________________________________________________________________________________ mashahir. I am aware of the risk involved in dispensing with the physical contract note. • This declaration is valid till 31st March ________________ (yyyy) [The above declaration has been read and understood by me. I am voluntarily requesting for delivery of electronic contract note pertaining to all the trades carried out/ordered by me. Zerodha Commodities Private Limited of MCX/NCDEX Exchange undertake as follows: • I am aware that the Member has to provide physical contract note in respect of all the trades placed by me unless I myself want the same in the electronic form.ahmed@gmail. having sufficient knowledge of handling the email operations. I find that it is inconvenient for me to receive physical contract notes. • I am aware that the Member has to provide electronic contract note for my convenience on my request only. • I have access to a computer and am a regular Internet user. Opp. Clarence Public School.P Nagar 4th Phase. 4th Cross Dollars Colony. Therefore. and do hereby take full responsibility for the same] (The above lines must be reproduced in own handwriting of the client. • Though the Member is required to deliver physical contract note. J. I. Zerodha Commodities Private Limited #153/154. Bangalore .560078 Dear Sir.ELECTRONIC CONTRACT NOTE [ECN] DECLARATION (VOLUNTARY) Appendix .com • This has been created by me and not by someone else.

Clarence Public School. Rights & Obligations. (MCX) that we do client based trading and Pro-account trading and we are not indulged in portfolio management services.560078 Sub: Receipt of KYC. Thanks and Best Regards.P Nagar 4th Phase. Rights & Obligations. RDD.DISCLOSURE INFORMATION ANNEXURE-N Dear Sir/Madam. Opp. J. Regulations and Bye-laws of Multi Commodity Exchange of India Ltd. Bangalore . I/We hereby acknowledge that we have read and received the copy of the under-mentioned documents which are in accordance with the norms of the guidelines issued by the MCX and NCDEX. This is to inform you as per Rules. Zerodha Commodities Private Limited I/We acknowledge receipt of information given above by Zerodha Commodities Private Limited that they do client base trading and Pro-account trading and they are not indulged in portfolio management services. Client Name: __________________________________________ MASHAHIR AHMED Signature of Client F10F7 __________________________________________ RECEIPT OF KYC. and Dos & Don’ts Dear Sir. RDD. and Dos & Don’ts ANNEXURE-O To Zerodha Commodities Private Limited #153/154. 4th Cross Dollars Colony. (a) Copy of the Client Registration Form (b) RDD with other Voluntary undertakings (c) Rights & Obligations Documents (d) Dos & Don'ts Client Name: __________________________________________ MASHAHIR AHMED Signature of Client F11F8 __________________________________________ 10 sign wherever you see .

as the case may be at your registered office. 4. I/We authorize you. your group companies and associates to keep me/us informed with any financial product which Zerodha Commodities Private Limited. Bangalore . telephone. I/We can revoke any or all of the above authorizations at any time in writing. I/We understand and agree that no interest will be payable to me/us on the amounts or commodities so retained with you pending periodical settlement. I confirm having read the rules & regulation pertaining to the levy of such interest under the policies & procedures page on Zerodha's website. Opp. through E-mail. Authorization for Communication of Financial Products: I/We have opened an account with you and am/are interested in knowing about other financial products. launch. Clarence Public School.P Nagar 4th Phase. I / We shall get the required details from contract notes issued by you. 3. Date: ___________________________ ______________________________________ Place: ___________________________ Signature of Client F13F9 11 sign wherever you see . issue. Running Account Authorization: I/We am /are desirous of regularly dealing in commodity market on Commodity Exchanges and request you to maintain a running account for funds and commodities on/our behalf without settling the account on settlement of each transaction on my/our behalf. discontinue sending such information. deal in or distribute. print media or otherwise. Authorization for not Providing Confirmation Slips: I / We authorize you not to provide me / us Order Confirmation / Modification / Cancellation Slips and Trade Confirmation Slips to avoid unnecessary paper work. 7. This is without legal obligation on you. All accounts with credit balances of Rs. Authorization for Providing Financial Ledger in Digital Form: I/we hereby authorize you to send me/us the financial ledger in the digital form in the prescribed formed at my/our E-mail ID / Address. every client's account has to be settled once in every six months. I/We further request you to retain all amounts payable and commodities receivable by me/us until specifically requested by me/us in writing to be settled or to be dealt with in any other manner. 2. I also agree to maintain the adequate balance in my trading account / pay adequate advance fee for the said reason. I am/We are dealing in commodities with you and in order to facilitate ease of operations. I/We confirm you that I will bring to your notice any dispute arising from the statement of account or settlement so made in writing within 7 working days from the date of receipt of funds/securities or statement of account or statement related to it. J. 2014.or lesser may be automatically retained and transfer of funds to the bank account may not be made as per FMC circular 1/2/2012-IR-I. I will be charged interest as delayed payment charges. towards my Depository Charges. 50000/.LETTER OF AUTHORITY (VOLUNTARY) ANNEXURE-Q Zerodha Commodities Private Limited #153/154. Authorization for Payment of Depository Participant Charges: I am having depository account with Zerodha Commodities Pvt Ltd. I understand that in case my account is in debit balance and/or if I have insufficient funds to manage my trading positions. its group companies and associates presently issue. 6. FMC/4/2014/C/121 & FMC/2014/04/23 dated October 17. SMS. or distribute or may. 5.560078 Dear Sir. Based on subsequent clarifications in this regard. 4th Cross Dollars Colony. in their discretion. I request you to debit my trading Account against the demand raised by the depository division of Zerodha Commodities Pvt Ltd. your group companies and associates to so inform and you or they may. Authorization to Retain Credit Balance: I / We request you to retain credit balance in any of my / our account and to use the idle funds towards our margin/future obligations at the Exchanges unless I/ we instruct you otherwise. I/we authorize you as under: 1. from time to time. deal in.

C) Please fill the date in DD-MM-YYYY format.Not Categorised Impression * 2. D) Please read section wise detailed guidelines / instructions H) For particular section update. TICK IF APPLICABLE RESIDENCE FOR TAX PURPOSES IN JURISDICTION(S) OUTSIDE INDIA (Please refer instruction B at the end) ADDITIONAL DETAILS REQUIRED* (Mandatory only if section 2 is ticked) ISO 3166 Country Code of Jurisdiction of Residence* Tax Identification Number or equivalent (If issued by jurisdiction)* Place / City of Birth* ISO 3166 Country Code of Birth* 3. please tick ( ) in the box available before the at the end. For office use only Application Type* New Update (To be filled by financial institution) KYC Number (Mandatory for KYC update request) Account Type* * Normal Simplified (for low risk customers) Small 1.Male F.Driving Licence Driving Licence Expiry Date D D M M Y Y Y Y E. B) Please fill the form in English and in BLOCK letters.Simplified Measures Account . G) KYC number of applicant is mandatory for update application.T Code* ISO 3166 Country Code* .Voter ID Card * C.UID (Aadhaar) F.NREGA Job Card Z. section number and strike off the sections not required to be updated.PAN Card AWAPA9396F D.Others (any document notified by the central government) Identification Number S. PERSONAL DETAILS (Please refer instruction A at the end) Prefix First Name Middle Name Last Name Name* (Same as ID proof) MASHAHIR AHMED Maiden Name (If any*) Father / Spouse Name* Mother Name* Date of Birth* 2D 4D 0M M 4 1Y 9Y 8Y 9Y PHOTO Gender* * M. PROOF OF ADDRESS (PoA)* 4.Indian Others (ISO 3166 Country Code ) Residential Status* Resident Individual Non Resident Indian Foreign National Person of Indian Origin Occupation Type* S-Service ( Private Sector Public Sector Government Sector ) O-Others ( Professional Self Employed Retired Housewife Student) B-Business Signature / Thumb X. 1988 is available at the end. PROOF OF IDENTITY (PoI)* (Please refer instruction C at the end) (Certified copy of any one of the following Proof of Identity[PoI] needs to be submitted) A.Document Type code Identification Number 4. E) List of State / U. F) List of two character ISO 3166 country codes is available at the end.Document Type code Address Line 1* HOUSE NO RH 19 NEAR WAREHOUSE Line 2 GAUSHALA PARA RAIGARH Line 3 CHHATTISGARH INDIA City / Town / Village* RAIGARH District* Pin / Post Code* 496001 State / U.Female T-Transgender Marital Status* Married Unmarried Others Citizenship* IN. CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual Important Instructions: A) Fields marked with ‘*’ are mandatory fields.1 CURRENT / PERMANENT / OVERSEAS ADDRESS DETAILS (Please see instruction D at the end) (Certified copy of any one of the following Proof of Address [PoA] needs to be submitted) Address Type* Residential / Business Residential Business Registered Office Unspecified Proof of Address* Passport Driving Licence UID (Aadhaar) Voter Identity Card NREGA Job Card Others please specify Simplified Measures Account .Passport Number Passport Expiry Date D D M M Y Y Y Y B.T code as per Indian Motor Vehicle Act.

NREGA Job Card Z. DETAILS OF RELATED PERSON (In case of additional related persons. REMARKS (If any) 8. (Off) Tel. 4.AHMED@GMAIL. I am aware that I may be held liable for it. ATTESTATION / FOR OFFICE USE ONLY Documents Received Certified Copies KYC VERIFICATION CARRIED OUT BY INSTITUTION DETAILS Date D D M M Y Y Y Y Name Emp. Designation Emp. APPLICANT DECLARATION I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein.COM 6.3 ADDRESS IN THE JURISDICTION DETAILS WHERE APPLICANT IS RESIDENT OUTSIDE INDIA FOR TAX PURPOSES* (Applicable if section 2 is ticked) Same as Current / Permanent / Overseas Address details Same as Correspondence / Local Address details Line 1* Line 2 Line 3 City / Town / Village* State* ZIP / Post Code* ISO 3166 Country Code* 5.Others (any document notified by the central government) Identification Number S. Code Emp.UID (Aadhaar) F.T Code* ISO 3166 Country Code* 4. CONTACT DETAILS (All communications will be sent on provided Mobile no. (Res) Mobile 7747995980 FAX Email ID MASHAHIR. please fill ‘Annexure B1’ ) (please refer instruction G at the end) Addition of Related Person Deletion of Related Person KYC Number of Related Person (if available*) Related Person Type* Guardian of Minor Assignee Authorized Representative Prefix First Name Middle Name Last Name Name* (If KYC number and name are provided. [Signature / Thumb Impression] I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered number/email address.Simplified Measures Account .PAN Card D. Branch [Institution Stamp] [Employee Signature] . Date : D D M M Y Y Y Y Place : Signature / Thumb Impression of Applicant 9. / Email-ID) (Please refer instruction F at the end) Tel. In case any of the above information is found to be false or untrue or misleading or misrepresenting.Document Type code Identification Number 7. below details of section 6 are optional) PROOF OF IDENTITY [PoI] OF RELATED PERSON* (Please see instruction (H) at the end) A.Passport Number Passport Expiry Date D D M M Y Y Y Y B. Name Code Emp.Voter ID Card C. immediately.2 CORRESPONDENCE / LOCAL ADDRESS DETAILS * (Please see instruction E at the end) Same as Current / Permanent / Overseas Address details (In case of multiple correspondence / local addresses. please fill ‘Annexure A1’) Line 1* HOUSE NO RH 19 NEAR WAREHOUSE Line 2 GAUSHALA PARA RAIGARH Line 3 CHHATTISGARH INDIA City / Town / Village* RAIGARH District* Pin / Post Code* 496001 State / U.Driving Licence Driving Licence Expiry Date D D M M Y Y Y Y E.