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: sis sropaeft-92 Imperial Securities caoer (far x et safe (q) eat eau) p Broker. 46 meatier aafenan afcaa feracot a aaa? Details of Natural Person Siri REAaRmaed kere cet) Wee 7. aaa aT afr Chen's Ac No Reference No Date ser ser ar Ree ree wer | eter ears arya Rear eer a aA ara urwt efafeg tre | stam Please complete all details and strike out the non-applicable fields/boxes. il sARaa aagRiea weuelt (1. fer. PP Sie Phot cent) Imperial Securities Company Pvt. Ltd. ae cerry PILAR EMM eke) So Name (In Block Ltr sea fir Pa a4 Date of Birth B.S Ab. fr fret aa rater ata Gender Female others Marries Un Married ‘afer area (ars) Nationality Others (If any) aaa ae and Fre sah Far Ctizenship No. Issue District Issue Date Reva ere erat ear art fermét aren 7. Beneficiary ID No. eat ear Permanent Aozount No. PAN) Areomarfee tae eT sftseres 4, < SrA Ioeiicaon No, and aes (case of NN Eocene) ar we facar Country Province District am aR, aa. ural MuricpastyMniiatiy ‘Sub Metropolitan city! ‘Ward Ho, Motopltan cy aa ‘fer, Tole Telephone No. a sees E-mal 1D Mobile No. ‘earft Sarat (Permanent Address) ser faa : Province Distt MOAI /E RR aa Rural MunipastyMuniipaliy!, Tole ‘Sub Metropolitan city! Metropattan chy ear. art. ae Telephone No. Ward No. Block No Page 1 of 4 Ee aes) a fF Block Letter) areata rand Faters Name aa a Mothers Name sf aettat are Spouse's Name arrat arr Son's Name ter are catrenter) Daughter's Name aarti ar Daughters in Law's Name aqrat ar Father in Lows Name ara ar Mother in Laws Name LEM es) fe art fee re stem TYperot Berk Axcurt: Lalonde Sl) Seeeeetnen fe arm ree Ba Acct Hs Se arm weet tea am to Name & Adress of Bak RRMA Checker ren) on a et Cpantetee tet ae eet antenatal Cccipaton : Seven: Teen, i pstormate sector CIncomco Depot COS cae ah feu free (aot = CO aisiessperion Tagicunre Rows’ Clive wise Cl Sie sarah rer rer aout al ‘yoes of Busness: Cl ffanutactrng CI Sone onenod Ol Stree none sn Orgaricton's Name acres Detgnaton (0 Noo Employ) Page 2 of 4 atts Pere Financial Details saat tat aff Fra / Income Limit (Annual Detais) [ & 220000 ae 400,001 Hf 90,00.000 eH 1 8.109000 et Upto Rs. 5,00,000 From Rs. §,00,001 to Rs. 10,00,000 ‘Above Rs. 10,00,000 Eakinikeechelic! a fee C] tee CQ) Q] x arte vite [] a fires core serter arta wt att: aC] goat wena am aire ae, Bm aah ren x qe fry ferent eq ee? A] fetes afc Pot ger stew eater eee aroha aT Bettys reat Sargunoe wrt wore wasted We parts vadea (COME TAM cme Zam watfrrat racer Gera wT} TH | (If yes mention below) a. « ee weet py eee eet ee Desionaton : |) Biectr C) O Sharohoter C1 Employes O otnors Sieh si Name/Sumame : (In Block letter) facade wer Relationship with applicant rere 3 Correspondence Address a Country Freer District een Fe Guardian's Signature sen Province AM, A/T RT / AT, Rural Muncpaltyiiunicipaty Sub Metropoitan city Metropaitan city eats ‘Telephone No. siren a Mobile No. a E-mail ID steereat ate wa water cat | SiteMap earret rea Location Map From main Road Street. the distance of the Resisence is meters (approximately) tn Page 3 of 4 ee ernie Dine acne a Sees artis 1 st Tee a EET? a*O #O =e ace cate a or ae afer EET a0 # O 2. Sanda frmirard afin a? *O « O fence ar aerate Se, ere fara at em wee ANH TT] TAT a? *eO 40 sei free fh arava) Parent, 20% cer = A ae om AACR TES got qm ate whee (ence cane) Saree Bere Pc he sere ca oN pTT eT eat Srey wet aT RAT w/a | meme arr arg Prater art wea eA a | fe. aeafr freee crft aravafee) France ty, 2oey Te fe fardteerar afeeat:arartar Pc atferat avareoar | aereeen of) ar Prater ear Peer aftaré HTT A a | aeqarean er, freer ar aerrare wrens ar a ae fer er frronee aera eer fa fet are Test avat aera aa fra 1 gt 9 wentané wf of amar waft ata wea arora secre Rates meh mer aren rarer er arrest ||| RAYert rience fasten coer sevdtrea wt Frere rat ig | af garare at ofera wd at ert =A | 9, Rah arafeerest cera areca saererah th | Ee 2, erat arate wea TEA ae 1 a. avant res seer wer ara gH HT ‘ ireetverec er ser Cereal Neto aga tere ae at eA STAT | art co. gh erat ahah eat worm ated afresh smn gee Pareor aan re cea eat Prenat ak Hea TE are Tf AEA, TATSAT | We hereby acknowledge that the above disclosed details are true. | further hereby consent to bear any legal actions in case any false disclosure of information related to metus. ST GI Thumb Print rat Regt art Let Mees RTT Client's Signature wraieer wairaaat aft (For Official Use) at varie 1 a, a aH, a « « reer z rere far ‘arate ar ar are Pr fed aa eee faonfce ater arr: wit a: Pane dof &

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