-.
,'" ADITYA BIRLA
STOCKS & SECURITIES r. � ., CAPITAL
.,
Aditya Birla Money Limited PROTECTING INVESTING FINANCING ADVISING
Application Type* D New D Update Client ID: 239085
PAN No.: AIVPS3237L
CENTRAL KYC REGISTRY I Know Your Customer (KYC) Application Form I Individual
For office use only
(To be filled by financial institution) KYC Number T T T (Mandatory for KYC update request)
Account Type* D Normal DSimplified (for low risk customers) □Small
1. PERSONAL DETAILS (Please refer instruction A at the end)
Prefix First Name Middle Name Last Name
Name* (Same of ID proof) SA N K A R N A R A Y A N S A R K A R
Maiden Name (If any*)
Father / Spouse Name* H A R E N D R A N A T H S A R K A R Il
Mother Name* I
Date of Birth* D M - viviv Y PHOTO
Gender* DM-Male F-Female DT-Transgender
Marital Status* Married □ Unmarried DOthers
Citizenship* DIN-Indian Others (ISO 3166 Country Code
Residential Status* Resident Individual Non Resident Individual
DForeign National D Person of Indian Origin
Occupation Type* DS-Service ( □ Private Sector □ Public Sector □ Government Sector)
DO-Others (□ Professional DSelf Employed DRetired D Housewife DStudent)
DB-Business □ X - Not Categorised
2. TICK IF APPLICABLE RESIDENCE FOR TAX PURPOSES IN JURISDICTION(S) OUTSIDE INDIA (Please refer instruction Bat the end)
ADDITIONAL DETAILS REQUIRED* (Mandatory only if section 2 is ticked)
ISO 3166 Country Code of Jurisdiction of Residence*
Tax Identification Number or equivalent (If issued by jurisdiction)*
Place / City of Birth* ISO 3166 Country Code of Birth*
3. PROOF OF IDENTITY (Pol)* (Please refer instruction Cat the end)
(Certified copy of any one of the following Proof of Identity [Pol] needs to be submitted)
□ A-Passport Number l j
Passport Expiry Date D D - M M - viviv y
DB-Voter ID card
I I I D C - PAN Card A I V P S II
3 2 3 7 L
DD-Driving Licence Driving Licence Expiry Date D D - M M - Y Y Y Y
DE-UID (Aadhaar) I I I DF-NREGA Job Card II
□ Z - Ot herS
(any document notified
by the central government) Identification Number I I
□ S-Simplified Measures Account-Document Type code Identification Number I I
1
4. PROOF OF ADDRESS (PoA)*
4.1 CURRENT/ PERMANENT/ OVERSEAS ADDRESS DETAILS (Please see instruction D at the end)
(Certified copy of any one of the following Proof of Address [PoA] needs to be submitted)
Address Type* ..J Residential/Business Residential Business Registered Office Unspecified
Proof of Address* l Passport Driving Licence UID (Aadhaar) Voter Identity Card NREGA Job Card
J Others
7 SimplifiedMeasures Account-Document Type code
n
Address
Line 1 * II LiR c-:
r
1 0 5, O L A
7_J C H A N D I O A D,
1
I Il
L L L L
Line 2 T
Line 3 Tl City/Town/Village•['
K O L K A T A
ISO 3166
n
District* D Pin/Post Code*[
7 0 0 0 4 9 State/U.T Code* Country Code* Ll
4.2. CORRESPONDENCE/ LOCAL ADDRESS DETAILS * (Please see instruction (E) at the end)
Same as Current/ Permanent/ Overseas Address details (lncaseofmultipleCGflt!spondence/lAxaladdresses,pleasefiU'AnnexureA1.availab(einour website"www.stocks.andseCOOties.adityabirtacapital.oom�)
Line 1 *
Line 2
1 I 1 1C □
Line 3
District* Pin/Post Code*
II City/Town/Village*L
State/U.T Code* ISO 3166
Country Code*
□
[7
4.3. ADDRESS IN THE JURISDICTION DETAILS WHERE APPLICANT IS RESIDENT OUTSIDE INDIA FOR TAX PURPOSES* (Applicable if section 2 is ticked)
Same as Current / Permanent / Overseas Address details Same as Correspondence / Local Address details
Line 1 * 7 7 C
Line 2
Line 3 lJ I D City/Town/Village*L □
n
r
State* ll Pin/Post Code*L ISO 3166 Country Code*
5. CONTACT DETAILS (All communications will be sent on provided Mobile no./ Email Id) (Please refer instruction Fat the end)
Tel. (Off) 1-: Tel. (Res) J i-1 I I
Mobile 9I 4I3 3 2 4 9 7 5 8 Fax I I
Email ID s a n k a Ir s a r k a r. b a c l h u @ g m a i l. c I o m I
6. REMARKS (If any)
I I I I I I
7. APPLICANT DECLARATION
• I would like to reactivate my account and I hereby state that all the transactions effected in my Trading/Demat account
till date were authorised by me and I acknowledge / confirm all the transactions and account balances till date.
• I hereby declare that the details furnished above are true and correct to the best of my
knowledge and belief and I undertake to inform you of any changes therein, immediately. In case
any of the above Information Is found to be false or untrue or misleading or misrepresenting. I am
aware that I may be held liable for it.
• I hereby consent to receiving information from Central KYC Registry through SMS/Email on the
above registered number/email address. 1 Signature/Thumb Impression
of Applicant
Date: D D -M M -YYY]Y Place: 1
8. ATTESTATION/ FOR OFFICE USE ONLY
Documents Received ..J Certified Copies _ (Originals verified)!;;.� ;:,:�.1""d (Self-Attested) Self Certified Document copies received
KYC VERIFICATION CARRIED OUT BY HO IPV Done on D D M M YYYY
Date D D -M M -YYYY UCC Code allotted to the Client
Emp. Name De lJ 1e, 0
I ,�Mewed/lPV By
C,
Emp. Code Name of the E'llp oyee/SB/AP
Emp. Designation EIYlDlovee/SB/AP Coele
lo •e, S1 <:e
Emp. Branch
For Aditya Birla Money Limited
Institution Code
i=n. H u. )
{Employee Signature]
Authorised Signatory (Round Seal/Date)
2
9. Bank Details (Through which transactions would be routed. Details & proof of bank account(s) is required)
Account Type Savings Current Others (Please specify )
Bank Account No.
PIS A/C No ( In case of NRI)
MICR Number IFSC Code
Bank Name
Bank Address
City Pincode
State Country INDIA
Please provide additional bank account details (if any) as annexures with proofs.
DECLARATION FOR UPDATING MOBILE NUMBER AND EMAIL ADDRESS FOR TRADING AND DEMAT ACCOUNT
(Only under exceptional circumstances)
To,
Aditya Birla Money Limited
Sai Sagar, 3rd Floor, Plot No.M-7, Thiru-Vi-Ka (SIDCO)
Industrial Estate, Guindy, Chennai 600032.
I hereby confirm that the mobile number / email id provided by me as per KYC belongs to
Mobile 9433249758 Self / Spouse / Dependent Children / Dependent Parents
Email sankarsarkar.bachu@gmail.com Self / Spouse / Dependent Children / Dependent Parents
I hereby confirm that the mobile number/email id provided by me has also been updated to my other family member
accounts as given below. I request you to kindly update the same mobile number and/or E-mail ID to my trading and/or
demat account also.
Client Code Demat ID of Family* Mobile Number Email ID Relationship
of the Family the Family Members Name with the
Member Member Client
“Family” for the purpose would mean self, spouse, dependent children and dependent parents
I hereby declare that the changes are true and correct to the best my knowledge and belief. I further undertake to keep
you informed about the changes in the mobile number/email id non-receipt of such updation may be construed that
the above iven mobile number/email id is valid and subsisting.
in case any of the above information is found to be false or untrue or misleading of misrepresenting, I am aware that
I may be held liable for it.
Client Name : Client Signature:
Version 1.0
3
To,
Aditya Birla Money Limited
Ali Centre, 53 Greams Road
Chennai – 600006
Dear Sirs,
Sub: Updation of Financial data
Trading Account No : 239085
Demat Account No : 10563597
Client Name SANKAR NARAYAN SARKAR
: _______________________
Mother’s Name : ___________________________
Pursuant to SEBI Circular No MIRSD/SE /Cir–19/2009 dated December 03, 2009, a client is required to share his/her
financial information to the stock broker on a periodic basis.
In view of these guidelines, please find my financial detail as mentioned below:
Financial detail of the Constituent:
Income Range (in ₹ / Per Annum – Last three years): (Tick whichever range is applicable)
Below 1,00,000 1,00,000 – 5,00,000 5,00,000 – 10,00,000 10,00,000 – 25,00,000 Above 25,00,000
Networth as on ____ / _____/ ______ (DD/MM/YYYY) is ₹ _______________________
(Please furnish any one proof of financial details as indicated in the list of documents)
1. Copy of ITR Acknowledgement
2. Copy of Form 16 in case of salary income
3. Net worth Certificate
4. Salary Slip
5. Bank account statement for last 6 months
6. Copy of Demat account holding statement
7. Any other relevant documents substantiating ownership of assets
8. Self-declaration along with relevant supporting
Thanking you,
Yours faithfully,
x
______________________________
Signature
Date : ________/________/________
