REQUISITION FORM FOR USER IDS

DATE
A SEGMENT REQUESTED (Pl. tick relevant field) VENDOR REQUESTED (Pl. tick relevant field)
BSE Cash Financial Technologies
BSE Derivatives Asian CERC
NSE Cash Margin Trading
NSE Derivatives Online Trading
Currency Derivatives
MCX
PAN NUMBER
B DEALER DETAILS
Name of dealer (as appearing in certificate)
Father's Name
Date of Birth (DDMONYYYY Format)
PAN NUMBER (compulsary)
Mobile number (compulsary)
Email ID (compulsary)
Residential Address
House No., Name of Bldg
Block No., Street Name, Locality,
City, Town Name
Pincode

Relation of dealer (Pl. tick relevant field)

Employee
Remisier / Sub-broker
Authorised Person
Employee of the Sub-broker / Authorised
Person

C NCFM / BCSM DETAILS

NCFM/BCSM Registration No.
Date of Certificate
Date of expiry of certificate

D APPROVED INTERMEDIARY DETAILS

Branch Code
Name of approved intermediary
Location where the FT ODIN TWS will be used
(Office Address)
House No., Name of Bldg
Block No., Street Name, Locality
Name of City/Town
Pincode
Name of State
Telephone number with (std code)
Fax no.

Relation of Approved Intermediary with PL

Head Office
Branch
Sub-broker / Authorised Person
SEBI Registration No. (For SBs only)

E NAME OF DEALER: Signature:-

F INTERMEDIARY NAME: Signature:-

G 12 / 14 DIGIT CODES ALLOTTED (Office Use only)

BSE Cash
NSE Cash
NSE Derivatives
Mutual Fund

Note: You are requested to fill in the complete details asked for in the above mentioned form failing which the requisition form
shall be liable to be rejected by PLPL. In case of NCFM / BCSM Details, Kindly mention the respective details followed by
Brackets giving relevant segment information; for eg: Regn No. ABCSD1233 (NSE) BCDE-APR2005 (BSE)