cfz'tf]if a|fs

] /]h P08 ;]So"l/6Lh -k|f=_ ln= cg';"rL–!@

-lgod @( sf] pklgod -!_ ;+u ;DalGwt_
a|l8=kL=
f]s/ g+= lvrfkf]v/L, sf7df8f}+
* kmf]g g+= $@@)@&^ k|fs[lts JolQmsf] kl/ro ljj/0f
Details of Natural Person

sfof{no k|of]hgsf] nflu dfq (For Offical Use Only)

u|fxs g+=M ;+st] gDa/ M ldlt M
Client's A/c No.: Reference No.: Date :

tn pNn]lvt ;Dk"0f{ ljj/0f /fd|f;] u+ eg'{ kg]5

{ . cfkm";uF ;/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]
cfz'tf]if a|fs
] /]h P08 ;]So"l/6Lh -k|f=_ ln= PP Size Photo
(Recent)
Ashutosh Brokerage & Securities Pvt. Ltd.
======================================= -zfvf_

u|fxssf] ljj/0f (Details of Client)

gfd
Name (In Block Letter)
hGd ldlt la=;+= O{= ;+=
Date of Birth B. S. A. D.
ln· k'?if dlxnf cGo
Gender Male Female Others

/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|bz
] M lhNnf M
Country : Province : District :
uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf= j8f g+=M
Rural Municipality/Municipality/
Sub Metropolitan city/ Ward No.:
Metropolitan city

6f]n M 6]lnkmf]g g+=M

Tole : Telephone No.:
O{dn
] M df]afOn g+=M
E-mail ID : Mobile No.:

:yfoL 7]ufgf (Permanent Address)

k|bz
] M 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 -7fp“ gk'u ePdf yk ug{ ;lsg]_ (Details of Family Members)
a'afsf] gfd
Father's Name
(In Block Ltter)

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 -ljjflxt

dlxnfsf] xsdf_
Father in Law's
Name
;f;'sf] gfd -ljjflxt
dlxnfsf] xsdf_
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 vftf gDa/ M
Bank Account Number :
a}+s vftf 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+=M
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
Upto Rs. 5,00,000 From Rs. 5,00,001 to Rs. 10,00,000
?= !),)),))) eGbf dfly
Above Rs. 10,00,000

lwtf]kq vl/b laqmL ug]{ d'Vo p2]Zon] :yflkt OGe]i6d]G6 sDkgLdf ;+nUg 5' 5}g .
Involvement in Investment companies which were established for securities trading
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 ;~rfns kbflwsf/L z]o/wgL sd{rf/L cGo

Designation : Director Executive Shareholder Employee Others

;+/Ifssf] kmf]6f]
-xfn;fn}
lvlrPsf]_
;+/Ifssf] ljj/0f -gfafnssf] xsdf dfq_ Guardian's Details (In case of Minor 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 M uf=kf=÷g=kf=÷p=d=g=kf=÷d=g=kf=
Rural Municipality/Municipality/
District : Sub Metropolitan city/
Metropolitan city
j8f g+=M 6]lnkmf]g g+=M
Ward No.: Telephone No.:
km\ofS; g+=M df]afOn 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] a f; /x] s f] Site Map

:yfgsf] gSzf N
Location Map

From main Road Street.............. the distance of the Residence is.......... meters (approximately).
Page 3 of 4
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 ;DaGwL k|rlnt sfg'g ljkl/t cfh{g u/]sf] x'g] 5}g .
@= lwtf]kqdf ul/Psf] nufgLdf lglxt hf]lvdsf] ;DaGwdf hfgsf/ 5' .
#= d÷xfdLn] vl/b u/]sf lwtf]kqx? jfktsf] e'QmfgL lng] lbg] sfo{ tf]lsPsf] ;do leq ug]{ 5' .
$= d÷xfdLn] lwtf]kq ;DaGwL tyf cGo k|rlnt lgod sfg"gx?sf] kfngf ug]5 { '.
%= d÷xfdL shf{ ;"rgf s]Gb|sf] sfnf] ;'rLdf /x]sf] 5'÷5}g .

;+nUg ug'{ kg]{ sfuhft

!= g]kfnL gful/sx?sf] xsdf gful/stfsf k|df0fkqsf] k|ltlnkL .
@= cGo b]zsf] gful/ssf] xsdf kf;kf]6s { f] k|ltlnkL .
#= gfafnssf] xsdf ;+/Ifs tyf gfafns b'js } f] kmf]6f] .
$= sfg"gL ;+/Ifs eP ;f] ;DaGwL sfuhft .
%= cfdf jf afa' ;+/Ifs ePdf 5f]/f jf 5f]/Lsf] hGdbtf{ k|df0fkqsf] k|ltlnkL .
^= lgj]bssf] x:tfIf/ tyf cf}7+ f 5fkdf ;+/Ifssf] x:tfIf/ tyf cf}7+ f 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'n
“ f, a'emfp“nf . 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}7+ f 5fk
Thumb Print

bfof“ afof“
Right 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]s { f] x:tfIf/

l;kmfl/; stf{sf] gfdM

kmf]g g+=M
Page 4 of 4