@ ZERODHA Know Your Client (KYC) Application Form - for Individuals Please i this frm in English ano BLOCK Leters (Please tick ne ox on te let margin ofthe appropriate row where CHANGEYCORRECTION is requied and provide the cet inthe coresponding window) For office use only (Tobe filed by the financial institution) Application Type* CONew Update KYC Number ‘Account Type* Normal ‘C1 Simplified (for ow risk customers) Sme A. Identity details CO] 1. Name (Same as ID Proof) [VEX KAPOOR ‘Ta. Maiden Name (If any) o[ 2_FathersSpouse's Name [ANUP KUMAR KAPOOR 2a. Mother's Name MADHUR KAPOOR See SHosr 0 8a, Gender © Male Ci Female (i Transgender 3b, Marital Status Single Married “Other 30. DOB [06-04-1994] O 4a. Citizenship i Indian Other (180 3166 Country Code ) 0 4p, Residential Status i Resident Individual C)Non Resident Indian (Person of Indian Origin Foreign National Tick if applicable CiResidence for tax purposes in jurisciction(s) outside India 180 3166 Country Code of Jurisdiction of residence Place of birth, ‘Tax Identification Number or Equivalent 1803166 Country Code of Birth 5a. PAN [DDIPK881 OE ‘5b. Unique Identification Number (UID) / AADHAR, it any 6. Proof of Identity Submitted E1Pan Card CiOther (Please Specify) B. Address details (4. Contact Details "Telephone (Office) Mobile No [8806266285 “Telephone (Residence) | Email ID [VIVEKKAPOOR644@GMAIL.COM CO 2.Residence/Correspondence Address Address Type: OResidential CiBusiness 1 Unspecified ‘Address HOUSE NO-1656 AWAS VIKAS NO. PANKI ROAD KALYANPUR KANPUR NAGAR KANPUR KALYANPUR Ciy/Town[ KANPUR District KANPUR NAGAR Pin Code 208017 ‘State/U.T Code [UTTAR PRADESH Country/ISO Code [INDIA ‘Specify the Proof of Address Submitted for Residence / Correspondence Address . DECLARATION ‘hereby declare tha the details furnished above are tue and corect othe best of my knowledge and bel and | undertake to inform you of any changes therein, immediatly. In case any ofthe above information is found tobe false or unrue or misleading r méscepresenting, | am aware Bat | may beheld ale fr "hereby consetio rec intoreton ren Canal KYG Rest trogh SMSleal onthe above registred cea EF runbeeal adress Date : [20-Jun-2018 FOR OFFICE USE ONLY In Person Verticaton (PV) Detals: [Name ofthe Person who has done the IPV:_ABHISHEK M_ Designation: ACCOUNT OPENING Name ofthe Organizaton: ZERODHA Date ofthe PV = TS verfied and Sel-Atested Document Copes Received Signature of Porson who has done the PV SeaStamp of he itemesiny ‘ate ‘grate of he Atari Signatony 3 sovemannane Z