cg';"rL–!

@
lqzlQm ;]So"l/l6h klAns ln= -lgod @( sf] pklgod -!_ ;Fu ;DalGwt
k'tnL;8s, sf7df8f}+
kmfg g+= $@#@!#@, km\ofS; M $@#@!## k|fs[lts JolQmsf] kl/ro ljj/0f
Brocker No. 48 Details of Natural Person
sfof{no k|of]hgsf] nflu dfq (For Official Use Only)
u|fxs g+=M ;+s]t gDa/ M ldlt M
Client's A/c No.: Reference No.: Date :

tn pNn]lvt ;Dk"0f{+ ljj/0f /fd|f] eg{' kg{]5 . cfkm";Fu ;/f]sf/ gePsf] ljj/0f pNn]v ug{] sf]7fdf
t];|f] wsf{ tflglbg' xf]nf .
Please complete all details and strike out the non-applicable fields/boxes. xfn;fn}
lvlrPsf] kmf]6f]
lqzlQm ;]So"l/l6h klAns ln= PP Size Photo
(Recent)
Trishakti Securities Public Limited
»»»»»»»»»»»»»» -zfvf_
u|fxssf] ljj/0f (Details of Client)
gfd
Name (In Block Letter)
hGd ldlt la=;+= O{=;+=
Date of Birth B.S. A.D.
lnË k'?if dlxnf cGo ljjflxt cljjflxt
Gender Male Female Others Married Un Married
/fli6«otf g]kfnL cGo -v'nfpg]_
Nationality Nepalese Others (If any)
gful/stf gDa/ hf/L lhNnf hf/L ldlt
Citizenship No. Issue District Issue Date
lxtu|fxL vftf vf]lnPsf] ;+:yfsf] gfd
lxtu|fxL vftf g+=
Beneficiary ID No.
:yfoL n]vf g+=
Permanent Account No. (PAN)
u}/cfjfl;o g]kfnLsf] xsdf
kl/rokq g+= / 7]ufgf
Identification No. and address (In case of NRN)

xfnsf] 7]ufgf (Current Address)

b]z M k|b]z M lhNnf M
Country : Province : District :
uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf= j8f g+=
Rural Municipality/Municipality/
Sub Metropolitan city/ Ward No.:
Metropolitan city
6f]n M 6]lnkmf]g g+=M
Tole : Telephone No.:
O{d]n M df]afO{n g+=M
E-mail ID : Mobile No.:

:yfoL 7]ufgf (Permanent Address)

k|b]z lhNnf M
Province : District :
6f]n M uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf=
Rural Municipality/Municipality/
Tole
: Sub Metropolitan City/
Metropolitan City
6]lnkmf]g g+=M j8f g+=M Ans g+=M
Telephone No.: Ward No.: Block No.:
Page 1 of 4
 kl/jf/sf ;b:ox?sf] ljj/0f -7fpF gk'u ePdf yk ug{ ;lsg]_ (Details of Family Members)
a'afsf] gfd
Father's Name
(In Block Letter)

afh]sf] gfd
Grand Father's Name

cfdfsf] gfd
Mother's Name

klt÷kTgLsf] gfd
Spouse's Name

5f]/fsf] gfd

Son's Name

5f]/Lsf] gfd
-cljjflxt_

Daughter's Name

a'xf/Lsf] gfd

Daughter's in Law's
Name

;;'/fsf] gfd
Father in Law's
Name
;f;'sf] gfd
Mother in Law's
Name

a}+s vftfsf] ljj/0f (Bank Account Details)

a}+s vftfsf] lsl;d M art vftf rNtL vftf
Types of Bank Account : Saving Account Current Account
a}+s vftfsf] gDa/ M
Bank Account Number :
a}+s vftfsf] ePsf] a}+ssf] gfd / 7]ufgf M
Name & Address of Bank :

k]zfut ljj/0f (Details of Occupation)

k]zf M ;]jfM ;/sf/L ;fj{hlgs÷lghL If]q Pg=hL=cf]=÷cfO{=Pg=hL=cf]= ljz]if1 ljBfyL{
Occupation : Service: Govt. Public/Private Sector NGO/INGO Expert Student
Jofkf/L s[lif ;]jf lgj[Q u[lx0fL cGo
Businessperson Agriculture Retired House Wife Others
Jofkf/sf] k|sf/ M pTkfbg ;]jfd'vL cGo
Types of Business : Manufacturing Service Oriented Others
;+:yfsf] gfd M 7]ufgf
Organization's Name : Address
kb M sd{rf/Lsf] xsdf sd{rf/L kl/rokq g+=
Designation : (ID No of Employee)
Page 2 of 4
cfly{s ljj/0f M cfosf] ;Ldf -jflif{s ljj/0f÷Income Limit (Annual Details)
Financial Details : ¿= %,)),))) ;Dd ¿= %,)),))! b]lv ¿= !),)),))) ;Dd ¿= !),)),))) eGbf dfly
Upto Rs. 5,00,000 From Rs. 5,00,001 to Rs. 10,00,000 Above Rs. 10,00,000
sf/f]af/ ;DaGwL yk ljj/0f (Transaction related additional information)
!= cfDbfgLsf] >f]t ü nufpg'xf];\ M Joj;foLs cfDbfgL tna÷kfl/>lds nufgL k|ltkmn 3/ ef8f lwtf]kq sf/f]af/
ljk|]if0f k}t[s Aofh cGo pNn]v ug{'xf];\ ===============================================================================================
@= cGo lwtf]kq bnfn sDkgLdf sf/f]af/ ug{] u/]sf] M 5}g 5
5 eg] sDkgLsf] gfd M ================================================================================================== u|fxs sf]8 M =============================================
#= tkfO{ shf{ ;"rgf s]Gb| -;'/If0f lgud_ ln= sf] sfnf];'rLdf /xg' ePsf] 5 < 5}g 5
lwtf]kq vl/b laqmL ug{] d'Vo p2]Zon] :yflkt OGe]i6d]G6 sDkgLdf ;+nUg
Involvement in Investment companies which were established for securities trading 5' 5}g .
Yes No
-ePdf b]xfo adf]lhdsf] ljj/0f pNn]v ug{] kg{] . (If yes mention below)
sDkgLsf] gfd M
Name of the Company :
kb M
Designation :

axfndf a:g]sf] xsdf

3/ wgLsf] gfd M ======================================================================================================================================
6]lnkmf]g g+= =================================== df]afO{n g+= ====================================== lhNnf M ======================================
dgkf÷pkgkf÷gkf÷uflj; M ============================================================================================= j8f g+=M =============
;+/Ifssf] kmf]6f]
6f]nM ========================================================== 3/ g+=M =========================
-xfn;fn}
lvlrPsf]_
;+/Ifssf] ljj/0f -gfafns÷ljlIfKtsf] xsdf dfq_ Guardian's Details (In case of Minor/Intellectually Disable only)
gfd÷y/ M
Name/Surname: (In Block letter)
lgj]bs;+usf] ;DaGw M
Relationship with Applicant :
kqfrf/ 7]ufgf M
Correspondence Address :
b]z M k|b]z M
Country: Province:
lhNnf uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf=
District: :Rural Municipality/Municipality/
Sub Metropolitan City/
Metropolitan City
j8f g+=M 6]lnkmf]g g+=M
Ward No.: Telephone No.:
km\ofS; g+=M df]afO{n g+=M
Fax No.: Mobile No.:
:yfoL n]vf g+=M O{d]n M
PAN No.: E-mail ID :

=======================================
;+/Ifssf] x:tfIf/
Guardian's Signature

xfn a;f]af; /x]sf] Site Map

N
:yfgsf] gSzf
Location Map

From main Road Street .......................................................... the distance of the Residence is........... meters (approximately).
Page 3 of 4
;DklQ z'l4s/0f tyf cftÍsf/L lqmofsnfkdf ljQLo lgjf/0f ;DaGwL yk ljj/0fM
!= s] tkfO{ /fhg}lts jf pRr kb:y JolQm x'g'x'G5 < xf] xf]O{g
@= s] tkfO{ /fhg}lts jf pRr kb:y JolQm ;Fu ;DaGwL x'g'x'G5 < 5' 5}g
;DalGwt /fhg}lts÷pRr kb:y JolQmsf] gfd tkfO{;+usf] ;DaGw
======================================================================================================================================= =================================================
#= s] tkfO{sf] lxtflwsf/L JolQm 5 < 5}g 5
lxtflwsf/L JolQmsf] gfd tkfO{;+usf] ;DaGw
======================================================================================================================================= =================================================
$= s] tkfO{ ljutdf s'g} ;Da4 s;'/df bf]ifL k|dfl0ft x'g' ePsf] 5 < 5}g 5
;DklQ z'l4s/0f -dgL nfp08l/Ë_ P]g, @)^$ bkmf @ sf] v08 -z_ adf]lhdsf s;'/x?
5 eg] s[kof pNn]v ug{'xf];\ =======================================================================================================================================================
lwtf]kq sf/f]jf/sf] ;DaGwdf tklzn adf]lhdsf] :j3f]if0ff ub{5' .
!= d÷xfdLn] lwtf]kq vl/bsf nflu k|of]u ug{] /sd ;DkQL z'l4s/0f %= d÷xfdL shf{ ;"rgf s]Gb|sf] sfnf] ;'rLdf /x]sf] 5'÷5}g .
;DaGwL k|rlnt sfg'g ljkl/t cfh{g u/]sf] x'g] 5}g . ^= ;DklQ z'l4s/0f -dgL nfp08l/Ë_ lgjf/0f P]g, @)^$ / o;
@= lwtf]kqdf ul/Psf] nufgLdf lglxt hf]lvdsf] ;DaGwdf hfgsf/ cGu/ut hf/L ePsf lgodffjnL tyf lgb{]zg cfbLaf6 dfu eP
5' . cg';f/sf ;'rgf, ljj/0f tyf sfuhftx? sDkgLnfO{ pknAw
#= d÷xfdLn] vl/b u/]sf lwtf]kqx? jfktsf] e'QmfgL lng] lbg] sfo{ u/fpg] 5'÷5f}+ .
tf]lsPsf] ;do leq ug{] 5' . &= sDkgLnfO{ ug{' kg{] e'QmfgL gul/ afFsL /fv]sf] sf/0faf6 d]/f]÷xfd|f]
$= d÷xfdLn] lwtf]kq ;DaGwL tyf cGo k|rlnt lgod sfg"gx?sf] kfngf sf/f]af/ cGo lwtf]kq bnfn sDkgLx?df ;d]t lgnDag ug{ kqfrf/
ug{]5' . jf kl/kq ug{ d]/f]÷xfd|f] d~h'/L 5 .
;+nUg ug{'kg{] sfuhft
!= g]kfnL gfuul/sx?sf] xsdf gful/stfsf k|df0fkqsf] k|ltlnkL . %= cfdf jf afa' ;+/Ifs ePdf 5f]/f jf 5f]/Lsf] hGdbtf{ k|df0fkqsf]
@= cGo b]zsf] gful/ssf] xsdf kf;kf]6{sf] k|ltlnkL . k|ltlnkL .
#= gfafnssf] xsdf ;+/Ifs tyf gfafns b'j}sf] kmf]6f] . ^= lgj]bssf] x:tfIf/ tyf cf}+7f 5fkdf ;+/Ifssf] x:tfIf/ tyf cf}+7f
$= sfg"gL ;+/Ifs eP ;f] ;DaGwL sfuhft . 5fk .
& s'g} ;+:yfsf] sd{rf/L /x]sf] xsdf sd{rf/L kl/rokqsf] k|ltlnkL .
dfly pNn]lvt ljj/0f ;To tYo /x]sf] / ;f] ljj/0fdf s'g} km/s k/] sfg"g adf]lhd ;x'Fnf, a'emfpFnf . I/we hereby acknowledge that the
above disclosed details are true. I further hereby consent to bear any legal actions in case any false disclosure of information
related to me/us.

cf}7f 5fk Thumb Print

bfofF Right afofF Left

=======================================
u|fxssf] x:tfIf/
Client's Signature

sfof{no k|of]hgsf] nflu (For Official Use)

?h' ug{]M k|dfl0ft ug{] M
gfd, y/ M gfd, y/ M
kb M kb M
x:tfIf/ M x:tfIf/ M
ldlt M sfof{nosf] gfd tyf 5fk ldlt M

============================================
k|lji6L ug{]sf] x:tfIf/

l;kmfl/; stf{sf] gfdM =======================================================

kmf]g g+=M ==================================================
Page 4 of 4