AP-3

SHIV SHANKAR BHOOTRA

MAHESHWARI KI GALI, INSIDE CHANDPOLE, JODHPUR, RAJASTHAN - 342001
MOBILE: 9828384183 | EMAIL: hariinv@yahoo.co.in

Sr.N Name Father’s Name Husban Date of PAN No Qualificati Residential Address Contac Email ID
o d’s Birth on t/Mobil
Name e No
1 SHIV CHAMPA LAL 17/07/ ACMPB6 HSC MAHESHWARI 98283 HARIINV@YAH
SHANKAR BHOOTRA 1965 173B 84183 O.CO.IN
BHOOTRA
KI GALI,
INSIDE
CHANDPOLE,
JODHPUR,
JODHPUR,
RAJASTHAN -
342001
DETAILS OF INDIVIDUAL __SHIV SHANKAR BHOOTRA_(APPLICANT AUTHORISED PERSON’S
NAME) AS ON ________________

NOTES:
$ All initials to be expanded (full name to be indicated)
* In case of Co-operative Society provide details of all the Members / Directors by whatever name
called, of the Managing Committee / Governing Body
** Only in case of married female applicants. In case if the applicant has not changed her name and
address post marriage an undertaking to be obtained from applicant(s) for no change in name and address
post marriage duly self-certified and the same to be confirmed by Member also.
Date:
Sign of the
applicant
Place:
***Signature of Individual/Partner/Director with Stamp of the Authorised Person
CERTIFICATE
This is to certify that the details of Individual/partner/director/ members of Managing Committee
/Governing Body/ Directors of co-operative society in ______________ and as given above,
based on my/ our scrutiny of the books of accounts, records and documents is true and correct to
the best of my/our knowledge and as per information provided to my/our satisfaction and signed before
me.
For (Name of Certifying Firm)
Name of the Partner/Proprietor
Chartered Accountant
Membership Number
Date:
Please paste self-attested photographs of the Individual duly signed across:

Across
Photo
Signature
For India Infoline Commodities Ltd

Director/Authorised Signatory