Nomination Form

[Annexure A to SEBI circular No. SEBI/HO/MIRSD/RTAMB/CIR/P/2021/601 dated July23, 2021

on Mandatory Nomination for Eligible Trading and Demat Accounts]

Request Ref No: 972200

I/We wish to make a nomination and do hereby nominate the following person(s) who shall receive all the assets
held in my / our account in the event of my / our death.

Fields as per SEBI Nomination Form Details

Date 17-05-2023
DP ID IN303028
Client ID 71490306
First Nominee Details (including minor)
Is 1st Nominee a minor No
Date of birth of 1st Nominee (minor)
Name of 1st Nominee (Ms./Master./Mr./Mrs.) KHUSHBU LASKAR
Distribute Equally Yes
Share of 1st Nominee
Relationship With the Applicant (If Any) Sister
Address of 1st Nominee H No- 113 Vill- Boalipar Pt II P.O - Boalipar Bazar PS & Dist - Hailakandi, Assam

State and Country ASSAM ,INDIA

PIN Code 788155
Mobile No. of 1st Nominee 8474817793
Email ID of the 1st Nominee arminkhushbu17767@gmail.com
1st Nominee Identification Details 369276864467
First Guardian Details (in case nominee is minor)
Name of the 1st Nominee's Guardian (Mr./Mrs.)
Relationship with 1st Nominee
Address of 1st Guardian
State and Country
PIN Code
Mobile No. of 1st Guardian
Email ID of 1st Guardian
1st Guardian identification details
Second Nominee Details (including minor)
Is 2nd Nominee a minor No
Date of birth of 2nd Nominee (minor)
Name of 2nd Nominee (Ms./Master./Mr./Mrs.) MEHBUBA LASKAR
Distribute Equally Yes
Share of 2nd Nominee
Relationship With the Applicant (If Any) Sister
Address of 2nd Nominee H No - 113 Vill - Boalipar Pt II P.O. - Boalipar Bazar PS & Dist - Hailakandi
State and Country ASSAM ,INDIA
PIN Code 788155
Mobile No. of 2nd Nominee 9395447529 Digitally Signed by:
Name:IMDADUL HOQUE LASKAR
Reason:Nomination Update
Date:Wed May 17 09:34:16 IST 2023
 Email ID of the 2nd Nominee mehbuba17767@gmail.com
2nd Nominee Identification Details 368931489205
Second Guardian Details (in case nominee is minor)
Name of the 2nd Nominee's Guardian (Mr./Mrs.)
Relationship with 2nd Nominee
Address of 2nd Guardian
State and Country
PIN Code
Mobile No. of 2nd Guardian
Email ID of 2nd Guardian
2nd Guardian identification details
Third Nominee Details (including minor)
Is 3rd Nominee a minor
Date of birth of 3rd Nominee (minor)
Name of 3rd Nominee (Ms./Master./Mr./Mrs.)
Distribute Equally
Share of 3rd Nominee
Relationship With the Applicant (If Any)
Address of 3rd Nominee
State and Country
PIN Code
Mobile No. of 3rd Nominee
Email ID of the 3rd Nominee
3rd Nominee Identification Details
Third Guardian Details (in case nominee is minor)
Name of the 3rd Nominee's Guardian (Mr./Mrs.)
Relationship with 3rd Nominee
Address of 3rd Guardian
State and Country
PIN Code
Mobile No. of 3rd Guardian
Email ID of 3rd Guardian
3rd Guardian identification details

Note:
This nomination shall supersede any prior nomination made by the account holder(s), if any.
The Trading Member / Depository Participant shall provide acknowledgement of the nomination form to the account holder(s)
* Signature of witness, along with name and address are required, if the account holder affixes thumb impression, instead of signature.