Request for Reactivation of Inactive / Dormant A/c &
Update / Modification of Master Details in Trading and Demat Account
Date: / /
Indira Securities Pvt. Ltd.
204-205, Amardarshan
28/2 Old Palasia,
Indore (M.P.) – 452018
Subject: Reactivation/ Update / Modification of Trading and Demat Account.
Ref : Trading Account No. /Client Code: Demat Account ……………………………….
Dear Sir/Madam,
With reference to above-mentioned subject, I wish to reactivate/Update / Modification of my/ our
aforesaid Trading /Demat account. I/we understand that reactivation process may take 24 Hours after
receipt of reactivation/Updation/ Modification form by Indira Securities Pvt. Ltd. Also, I/we am/ are
submitting the following my/our latest KYC details for updation/ modification in Master of Trading and
Demat Account.
Gross Annual Income Details : Below 1 Lac 1- 5 Lacs 5-10Lacs 10 -25 Lacs 25 - 100
As on date: Lacs
Name of Client: Occupation:
Mother Name: Bank Account No. :
Client Address: MICR No. :
Mobile No. : IFSC:
E-Mail Id : Bank Name & Address :
Demat A/c No. :
I hereby declare that the details provided by me are true to the best of my knowledge and belief.
Yours Faithfully,
Signature of Client
Encl: Proof of Identity, Proof of Address, Bank Proof, Income Proof
(For office use)
Reactivation/Update / Modification Date: / /
Authorised By:
Know Your Client (KYC)
Application Form (For Individuals Only)
Please fill the form in ENGLISH and in BLOCK letters Fields marked * are mandatory Application Number:
Fields marked + are pertaining to CKYC and mandatory only if processing CKYC aISO Application Type*: New KYC Modification KYC
KYC Mode”:
Normal EKYC OTP EKYC Biometric Online KYC Offline EKYC Digilocker
1. Identity Details {please refer guidelines overleaf)
PAN 5
Please enclose a duly attested copy of your FAN Card
Name* (same as ID proof)
Maiden Name+ (if any)
Fathers/Spouse’s Name S
Date of Birth S
Gender” Male Female Transgender
Marital Status* Single Married
Nationality” Other
Indian
Residential Status” Resident Individual Non Resident Individual
Please Tick ( ) Foreign National Person of Indian Origin
3
{Passport mandatory for NRIs, PIOs and Foreign Nafionals)
Proof of Identity (POI) submitted for PAN exempted cases (Please tick)
XXXXXXXX
A - Adhaar Card
B - Passport No.
C - Voter ID Card Expiry Date
D - Driving License
Expiry Date
E - NREGA Job Card
F - NPR Letter
Z - Others (any document nofified by Central
Government)
Identification Number
2. Address Details* (please refer guidelines overleaf)
A. Correspondence/ Local Address*
Line 1”
Lne 2
Une3
City/ Towns llage” District” Pin Code”
State” Country”
Address Type” Residential/Business Residential Business Registered Office Unspecified
Applicant Wet Sign Applicant e-SIGN
B. Permanent residence address of applicant, if diNerent from above A / Overseas Address” (Mandatory
for NRI Applicant)
Line 1”
Line 2
Line3
City/ Town/Village” District” Pin Code”
State* Country”
Address Type” Residential/Business Residential Business Registered Office Unspecified
Proof of Address” (attested copy of any 1 POA for correspondence and permanent address each to be submitted)
XXXXXXXX
A - Adhaar Card
B - Passport No.
C - Voter ID Card
Expiry Date
D - Driving License
E - NREGA Job Card Expiry Date
F - NPR Letter
Z - Others
(any document notified by Central Government)
Identification Number
3. Contact Details
Email Id
Mobile No.
Tel. (Off.)
Tel (Resi.)
4. Applicant Declaration
I/We hereby declare that the KYC details furnished by me are true and correct to Applicant e-SIGN Applicant Wet Signature
the best of my/our knowledge and belief and I/we under-take to inform you of any
changes therein, immediately. In case any of the above informafion is found to be
false or untrue or misleading or misrepresenfing, I am/We are aware that I/We may
be held liable for it.
I/We hereby consent to receiving informafion from CVL KRA through SMS/Email on
the above registered number/Email address.
I am/We are also aware that for Aadhaar OVD based KYC, my KYC request shall be
validated against Aadhaar details. I/We hereby consent to sharing my/our masked
Aadhaar card with readable QR code or my AadhaarXlVlL/DigilockerXlVlL file, along
with passcode and as applicable, with KRA and other Intermediaries with whom I
have a business relationship for KYC purposes only.
DATE: (DD-MM—YYYY)
PLACE:
5. For Office Use Only
In-Person Verification (IPV) carried out by‘ Intermediary Details”
IPV Date Self certified document copies received (OVD)
Emp. Name True Copies of documents received (Attested)
AMC / Intermediary Name :
Emp. Code
Emp. Designation INDIRA SECURITIES PVT. LTD.
[Employee Signature]
