Application No.

:
I Know Your Client (KYC)
Application Form (For Individuals Only)
Please fill in ENGLISH and in BLOCK LETTERS with black ink
A. Identity Details (please see guidelines overleaf)
1. Name of Applicant (As appearing in supporting identification document).
PHOTOGRAPH
Name
Please affix
Father’s/Spouse Name the recent passport
size photograph and
2. Gender ? Male ? Female B. Marital status ? Single ? Married C. Date of Birth D D M M Y Y Y Y sign across it
3. Nationality ? Indian ? Other__________________________________
4. Status Please tick (y) ? Residential Individual ? Non Resident ? Foreign National (Passport Copy Mandatory for NRIs
& Foreign Nationals) #
CCCCCCCCCCC
5. PAN Please enclose a duly attested copy of your PAN Card
Unique Identification Number (UID)/Aadhaar, if any :________________________________________________________________________
6. Proof of Identity submitted for PAN exempt cases Please Tick (y)
? UID (Aadhaar) ? Passport ? Voter ID ? Driving Licence ? Others (Please see guideline ‘D’ overleaf)
B. Address Details (please see guidelines overleaf)
1. Address for Correspondence

City/Town/Village Pin Code

State Country
2. Contact Details
Tel. (Off.) (ISD) (STD) Tel. (Res.) (ISD) (STD)
Mobile (ISD) (STD) Fax (ISD) (STD)
E-mail Id.
3. Proof of address to be provided by Applicant. Please submit ANY ONE of the following valid documents & tick (y) against the document attached.
? Passport ? Ration Card ? Registered Lease/Sale Agreement of Residence ? Driving License ? Voter Identity Card ? *Latest Bank A/c.
Statement/Passbook ? *Latest Telephone Bill (only Land Line) ? *Latest Electricity Bill? *Latest Gas Bill ? Others __________________________
*Not more than 3 Months old. Validity/Expiry date of proof of address submitted D D M M Y Y Y Y
4. Permanent Address of Resident Applicant if different from above B1 OR Overseas Address (Mandatory for Non-Resident Applicant

City/Town/Village Pin Code

State Country
5. Proof of address to be provided by Applicant. Please submit ANY ONE of the following valid documents & tick (y) against the document attached.
? Passport ? Ration Card ? Registered Lease/Sale Agreement of Residence ? Driving License ? Voter Identity Card ? *Latest Bank A/c.
Statement/Passbook ? *Latest Telephone Bill (only Land Line)? *Latest Electricity Bill? *Latest Gas Bill ? Others ____________________________
*Not more than 3 Months old. Validity/Expiry date of proof of address submitted D D M M Y Y Y Y
C. Others Details (please see guidelines overleaf)
1. Gross Annual Income Details (please tick ( y) ? Below 1 lac ? 1-5 Lac ? 5-10 Lac ? 10-25 Lac ? >25 Lacs

(*Net worth should not be older than 1 year)

Net worth in ___________________________________________as on (date) D D M M Y Y Y Y
2. Occupation (please tick (y) any one and give brief details) :
? Private Sector Service ? Public Sector ? Government Service ? Business ? Professional ? Agriculturist ? Retired ? Housewife
? Student ? Forex Dealer ? Others (Please specify)_____________________________________________
3. Please tick, if applicable : ? Politically Exposed Person ? Related to a Politically Exposed Person
For definition of PEP, please refer guideline overleaf
4. Any other information : ___________________________________________________________________________________________________
DECLARATION SIGNATURE OF APPLICANT
I hereby declare that the details furnished above are true and correct to the best of my/our 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/we are aware that I/we may be held liable for it.
Place : Date : #CCCCCCCCCCCCCCCCCCCCCC
FOR OFFICE USE ONLY IPV Done ? on D D MM YYYY
Shriram Insight Share Brokers Ltd.
Seal/Stamp of the intermediary should contain Seal/Stamp of the intermediary should contain
Code : 1100038400 Staff Name Staff Name
? (Originals verified) Self Certified Document copies Designation Designation
received Name of the Organization Name of the Organization
? (Attested) True copies of documents received Signature Signature
Main Intermediary Date Date

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 INSTRUCTIONS / CHECK LIST FOR FILLING KYC FORM
A. IMPORTANT POINTS : Card/Registered Lease or Sale Agreement of Residence/
1. Self attested copy of PAN card is mandatory for all clients. Driving License/Flat Maintenance bill/Insurance Copy.
2. Copies of all the documents submitted by the applicant 2. Utility bills like Telephone Bill (only land line), Electricity
should be self-attested and accompanied by originals for bill or Gas bill Not more than 3 months old.
verification. In case the original of any document is not 3. Bank Account Statement/Passbook-Not more than 3
produced for verification, then the copies should be months old.
properly attested by entities authorized for attesting the 4. Self-declaration by High Court and Supreme Court judges,
documents, as per the below mentioned list. giving the new address in respect of their own accounts.
3. If any proof of identity or address is in a foreign language, 5. Proof of address issued by any of the following: Bank
then translation into English is required. Managers of Scheduled Commercial Banks/Scheduled
4. Name & address of the applicant mentioned on the KYC Co-Operative Bank/Multinational Foreign Banks/ Gazetted
form, should match with the documentary proof submitted. Officer/Notary public/Elected representatives to the
5. If correspondence & permanent address are different, then Legislative Assembly/Parliament/Documents issued by
proofs for both have to be submitted. any Govt. or Statutory Authority.
6. Sole proprietor must make the application in his individual 6. Identity card/document with address, issued by any of the
name & capacity. following : Central/State Government and its Departments,
7. For non-residents and foreign nationals,(allowed to trade Statutory/Regulatory Authorities, Public Sector
subject to RBI and FEMA guidelines), copy of passport/ Undertakings, Scheduled Commercial Banks, Public
PIOCard/OCICard and overseas address proof is mandatory. Financial Institutions, Colleges affiliated to Universities
8. For foreign entities, CIN is optional; and in the absence and Professional Bodies such as ICAI, ICWAI, ICSI, Bar
of DIN no. for the directors, their passport copy should Council etc., to their Members.
be given. 7. For Fll/sub account, Power of Attorney given by Fll/sub-
9. In case of Merchant Navy NRI's, Mariner's declaration account to the Custodians (which are duly notarized and/or
or certified copy of CDC (Continuous Discharge apostiled or consularised) that gives the registered address
should be taken.
Certificate) is to be submitted.
8. The proof of address in the name of the spouse may be
10. For opening an account with Depository participant or
accepted.
Mutual Fund, for a minor, photocopy of the School
D. Exemptions/clarifications to PAN
Leaving Certificate/Mark sheet issued by Higher Secondary
(*Sufficient documentary evidence in support of such
Board/ Passport of Minor/Birth Certificate must be
claims to be collected.)
provided.
1. In case of transactions undertaken on behalf of Central
11. Politically Exposed Persons (PEP) are defined as
Government and/or State Government and by officials
individuals who are or have been entrusted with prominent
appointed by Courts e.g. Official liquidator, Court receiver
public functions in a foreign country, e.g., Heads of States
etc.
or of Governments, senior politicians, senior Government/
2. Investors residing in the state of Sikkim.
judicial/military officers, senior executives of state owned 3. UN entities/multilateral agencies exempt from paying
corporations, important political party officials, etc.
taxes/filing tax returns in India.
B. Proof of ldentity( POI): List of documents admissible as 4. SIP of Mutual Funds upto Rs. 50,000/- p.a.
Proof of Identity : 5. In case of institutional clients, namely, Flls, Mfs, VCFs,
1. PAN card with photograph. This is a mandatory requirement FVCIs, Scheduled Commercial Banks, Multilateral and
for all applicants except those who are specifically exempt Bilateral Development Financial Institutions, State
from obtaining PAN (listed in Section D). Industrial Development Corporations, Insurance Companies
2. Unique Identification Number (UID)(Aadhaar)/ registered with IRDA and Public Financial Institution as
Passport/Voter ID card/Driving license. defined under section 4A of the Companies Act, 1956,
3. Identity card/document with applicant's Photo, issued by Custodians shall verify the PAN card details with the
any of the following : Central/State Government and its original PAN card and provide duly certified copies of
Departments, Statutory/Regulatory Authorities, Public such verified PAN details to the intermediary.
Sector Undertakings, Scheduled Commercial Banks, E. List of people authorized to attest the documents :
Public Financial Institutions, Colleges affiliated to 1. Notary Public, Gazetted Officer, Manager of a Scheduled
Universities, Professional Bodies such as ICAI, ICWAI, Commercial/Co-operative Bank or Multinational Foreign
ICSI, Bar Council etc., to their Members; and Credit Banks (Name, Designation & Seal should be affixed on
cards/Debit cards issued by Banks. the copy).
C. Proof of Address (POA) : List of documents admissible as 2. In case of NRIs, authorized officials of overseas branches
Proof of Address : (*Documents having an expiry date of Scheduled Commercial Banks registered in India,
should be valid on the date of submission.) Notary Public, Court Magistrate, Judge, Indian Embassy/
1. Unique Identification Number (Aadhar) SEBI Circular Consulate General in the country where the client resides
dated August 13, 2012. Passport/Voters Identity Card/Ration are permitted to attest the documents.

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