KNOW YOUR CLIENT (KYC) APPLICATION FORM (For Individuals)

Indiabulls Securities Limited (formerly Dhani Stocks Limited)

Registered Office Address: 1/1 E, First Floor, East Patel Nagar, New Delhi - 110008 Please affix your
Correspondence Office Address: Plot No. 108, 5th Floor, IT Park, Phase I, Udyog Vihar, recent passport
Gurugram - 122016, Haryana. Corporate Identity Number (CIN): U74999DL2003PLC122874; size photograph
Website: www.dhanistocks.com ; Email: helpdesk@dhani.com ; grievances_dsl@dhani.com
and sign across it
Phone: 022-61446300 Fax: 0124 6681111 (1)
Trading Code
Demat ID (1)
Demat ID (2)
Demat ID (3)

 1. PERSONAL DETAILS* (Please refer instruction and checklist available at the end)
Prefix First Name Middle Name Last Name
Name of the Applicant
(as per PAN Website)
Name of the applicant
(same as ID Proof)
Father / Spouse Name

Mother Name

Date of Birth D D M M Y Y Y Y Gender : □ M - Male □ F – Female □ T - Transgender

(DD/MM/YYYY)
Marital Citizenship Residential Status:
Status: □ IN-Indian □ Resident Individual □ Non Resident Indian □ Foreign National (Passport
□ Unmarried □ Others (please copy mandatory for NRIs and Foreign Nationals)
□ Married specify) ______ □ Person of Indian Origin
□ Others
PAN * Please enclose a duly attested copy of your PAN
card

 2. Proof of Identity and Address.* Please tick (√) – Please refer instruction and checklist available at the end.
(Certified copy of OVD or equivalent e-document of OVD or OVD obtained through digital KYC process needs to be
submitted.(Any one of the following OVDs))
□ A -Passport Number Passport Expiry Date
□ B -Voter ID Card
□ C - Driving Licence Driving Licence Expiry Date
□ D - NREGA Job Card
□ E - National population register letter
□ F - Proof of Possession of Aadhaar ^ X
□ EKYC Authentication ^ X
□ Offline verification of Aadhaar ^ X
^ Please enter only the last 4 digits of your UID / Aadhaar
Sole / First Holder (Mr./Ms.) Second Holder (Mr./Ms.) Third Holder (Mr./Ms.)

Signature (2) (2) (2)

Page 1 of 7
Address
Address Type □ Residential / Business □ Residential □ Business
Permanent
Address

City/Town/Village District
State Country
PIN/ Post Code State / U.T. Code ISO 3166 Country
Code *
3. CURRENT ADDRESS DETAILS
 Please tick (√ ) Current Address is same as above address

I. Certified copy of OVD or equivalent e-document of OVD or OVD obtained through digital KYC process needs to
be submitted.(Any one of the following OVDs))
□ A -Passport Number Passport Expiry Date
□ B -Voter ID Card
□ C - Driving Licence Driving Licence Expiry Date
□ D - NREGA Job Card
□ E - National population register letter
□ F – UID (Aadhaar) ^ X
II □ EKYC Authentication ^ X
III □ Offline verification of Aadhaar ^ X
^ Please enter only the last 4 digits of your UID / Aadhaar
IV □ Deemed Proof of Address – Document Type Code
V □ Self-Declaration

Current Address

City/Town/Village District
State Country
PIN/ Post Code State / U.T. Code ISO 3166 Country
Code
4. Contact Details (all communications will be sent on provided Mobile No. / Email ID) (Please refer instruction and
checklist available at the end) *
Telephone (Off.)

Telephone (Res.)

Email ID

Mobile Number

Sole / First Holder (Mr./Ms.) Second Holder (Mr./Ms.) Third Holder (Mr./Ms.)

Signature (3) (3) (3)

Page 2 of 7
 Gross annual income details (income □ < 1 Lac □ 1 - 5 Lac □ 5 - 10 Lac □ 10 - 25 Lac
range per annum) *
□ ( >) Above 25 Lac
(OR) Net worth As on date D D M M Y Y Y Y
Net worth should not be older than 1 year
Occupation Type
□ S – Service (□ Private Sector □ Public Sector □ Government Sector)
□ O – Others (□ Professional □ Self Employed □ Retired □ Housewife □ Student )
□ B – Business □ X – Not Categorised □ Agriculturalist □ Other ____________________________
Please tick if □ Politically Exposed Person (PEP) □ Related to a Politically Exposed Person (PEP)
applicable
□ Not Applicable
Any other Information

Details of FATCA-CRS (Please consult your professional tax professional on your tax residency, if required)
Address of tax residence would be taken as available in KRA database. Incase of any change please approach KRA
& notify the changes.
Place of Birth Country of Birth
Are you a tax resident of any country other than India? □ Yes □ No
If yes, please indicate all countries in which you are a resident for tax purposes and the associated Tax purposes and
the associated Tax ID Numbers below
S. No Country of Tax Residency ** Tax Identification Number (TIN) Identification Type
/ Functional Equivalent ~ [TIN or other; please specify]
1.
2.
3.
** to also include USA, where the individual is a Citizen/Green Card Holder of the USA
~ Incase Tax Identification Number is not available, kindly provide its functional Equivalent

Certification: I/We have understood the information requirements of this form (read along with the FATCA & CRS
Instructions) and hereby confirm that the information provided by me/us on this form is true, correct and complete. I/We
also confirm that I/We have read and understood FATCA & CRS Terms and Conditions below and hereby accept the same.

Sole / First Holder (Mr./Ms.) Second Holder (Mr./Ms.) Third Holder (Mr./Ms.)

Signature (4) (4) (4)

DECLARATION: 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.

Sole / First Holder (Mr./Ms.) Second Holder (Mr./Ms.) Third Holder (Mr./Ms.)

Signature (5) (5) (5)

Date D D M M Y Y Y Y Place

Page 3 of 7
 FOR OFFICE USE ONLY
KYC Verification Carried Out by: Institution – Indiabulls Securities Limited (Formerly Dhani Stocks Limited; Institution
Code – IN0157)
Documents □ Certified Copies □ E-KYC data received from UIDAI □ Data received from Offline Verification
received □ Digital KYC Process □ Equivalent E-document □ Video based KYC
Application Type: □ New □ Update
KYC Number (Mandatory for KYC Update Request):
Account Type: □ Normal □ Aadhaar OTP based E-KYC (in non-face to face mode)
In-Person Verification (IPV) carried out by
Name SEAL/STAMP of Indiabulls
Code Securities Limited (formerly
Dhani Stocks Limited)
Designation
Date D D M M Y Y Y Y
Place
Signature 

Important Instructions –
1. Fields marked with * are mandatory details
2. Tick ‘ √ ’ wherever applicable
3. Please fill the form in English and in BLOCK Letters.
4. Please fill the date in DD-MM-YYYY format.
5. For particular section update, please tick (‘ √ ’) in the box section number and strike off the sections not
required to be updated.
6. Please read the section wise detailed guidelines / instructions at the end.
7. List of States / U.T. Code as per Indian Motor Vehicle Act, 1988 is available at the end.
8. List of two character ISO 3166 country codes is available at the end.
9. The ‘OTP based E-KYC’ check box is to be checked for accounts opened using OTP based E-KYC in non-face to
face mode.

Checklist:
1. The name should match with the name as mentioned in the Proof of Identity submitted failing which the
application is liable to be rejected
2. One of the following is mandatory – Mother’s name, Spouse’s name, Father’s name
3. Incase of deemed POA, such as utility bill, etc. or self-declaration, the document need not be uploaded on
CKYCR
4. PoA to be submitted only if the submitted PoI does not have an address or address as per PoI is invalid or not in
force.
5. State / U.T Code and Pin / Post Code will not be mandatory for Overseas addresses
6. List of document for ‘Deemed Proof of Address’
Document Code Description
01 Utility bill which is not more than 2 months old of any service provider (electricity,
telephone, post-paid mobile phone, piped gas, water bill).
02 Property or municipal tax receipt
03 Pension or family pension payment orders (PPOs) issued to retired employees by
Government Departments or Public Sector Undertakings if they contain the address.
04 Letter of allotment of accommodation from employer issued by State Government or
Central Government Departments, statutory or regulatory bodies, Public Sector
Undertakings, Scheduled Commercial Banks, financial institutions and listed companies
and leave and license agreements with such employers allotting official accommodation.

Page 4 of 7
 7. Regulated entity (RE) shall redact (first 8 digits) of Aadhaar number from Aadhaar related data and documents
such as proof of possession of Aadhaar, while uploading CKYCR
8. “Equivalent E-document” means an electronic equivalent of a document, issued by the issuing authority of such
document with its valid digital signature including documents issued to the digital locker account of the client as
per Rule 9 of Information Technology (Preservation And Retention Of Information By Intermediaries Providing
Digital Locker Facilities Rules) 2016.
9. “Digital KYC has to be carried out as stipulated in the PML Rules, 2005.
10. Registered Entity may use the Self-declaration check box where Aadhaar Authentication has been carried out
successfully for a client and client wants to provide current address, different from the address as per the
identity information available in Central Identities Data Repository
11. Please mention two- digit country code and 10 digit mobile number (e.g. for Indian mobile number mention 91-
9999999999).
12. Do not add ‘0’ in the beginning of Mobile number

List of two – digit state / U.T codes as per Indian Motor Vehicle Act, 1988
State / U.T State Code State / U.T State Code State / U.T State Code
Andaman & Nicobar AN Himachal Pradesh HP Pondicherry PY
Andhra Pradesh AP Jammu & Kashmir JK Punjab PB
Arunachal Pradesh AR Jharkhand JH Rajasthan RJ
Assam AS Karnataka KA Sikkim SK
Bihar BR Kerala KL Tamil Nadu TN
Chandigarh CH Lakshadweep LD Telangana TS
Chattisgarh CG Madhya Pradesh MP Tripura TR
Dadra and Nagar Haveli DN Maharashtra MH Uttar Pradesh UP
Daman & Diu DD Manipur MN Uttarakhand UA
Delhi DL Meghalaya ML West Bengal WB
Goa GA Mizoram MZ Other XX
Gujarat GJ Nagaland NL
Haryana HR Orissa OR

List of ISO 3166 two- digit Country Code

Country Country Country Country
Country Country Country Country
Code Code Code Code
Dominican Saint Pierre and
Afghanistan AF DO Libya LY PM
Republic Miquelon
Saint Vincent and the
Aland Islands AX Ecuador EC Liechtenstein LI VC
Grenadines
Albania AL Egypt EG Lithuania LT Samoa WS
Algeria DZ El Salvador SV Luxembourg LU San Marino SM
Sao Tome and
American Samoa AS Equatorial Guinea GQ Macao MO ST
Principe
Macedonia, the
Andorra AD Eritrea ER former Yugoslav MK Saudi Arabia SA
Republic of
Angola AO Estonia EE Madagascar MG Senegal SN
Anguilla AI Ethiopia ET Malawi MW Serbia RS
Falkland Islands
Antarctica AQ FK Malaysia MY Seychelles SC
(Malvinas)
Antigua and
AG Faroe Islands FO Maldives MV Sierra Leone SL
Barbuda
Argentina AR Fiji FJ Mali ML Singapore SG
Sint Maarten (Dutch
Armenia AM Finland FI Malta MT SX
part)
Aruba AW France FR Marshall Islands MH Slovakia SK
Australia AU French Guiana GF Martinique MQ Slovenia SI

Page 5 of 7
Austria AT French Polynesia PF Mauritania MR Solomon Islands SB
French Southern
Azerbaijan AZ TF Mauritius MU Somalia SO
Territories
Bahamas BS Gabon GA Mayotte YT South Africa ZA
South Georgia and the
Bahrain BH Gambia GM Mexico MX South Sandwich GS
Islands
Micronesia,
Bangladesh BD Georgia GE FM South Sudan SS
Federated States of
Barbados BB Germany DE Moldova, Republic of MD Spain ES
Belarus BY Ghana GH Monaco MC Sri Lanka LK
Belgium BE Gibraltar GI Mongolia MN Sudan SD
Belize BZ Greece GR Montenegro ME Suriname SR
Svalbard and Jan
Benin BJ Greenland GL Montserrat MS SJ
Mayen
Bermuda BM Grenada GD Morocco MA Swaziland SZ
Bhutan BT Guadeloupe GP Mozambique MZ Sweden SE
Bolivia,
Plurinational State BO Guam GU Myanmar MM Switzerland CH
of
Bonaire, Sint
BQ Guatemala GT Namibia NA Syrian Arab Republic SY
Eustatius and Saba
Bosnia and Taiwan, Province of
BA Guernsey GG Nauru NR TW
Herzegovina China
Botswana BW Guinea GN Nepal NP Tajikistan TJ
Tanzania, United
Bouvet Island BV Guinea-Bissau GW Netherlands NL TZ
Republic of
Brazil BR Guyana GY New Caledonia NC Thailand TH
British Indian
IO Haiti HT New Zealand NZ Timor-Leste TL
Ocean Territory
Heard Island and
Brunei Darussalam BN HM Nicaragua NI Togo TG
McDonald Islands
Holy See (Vatican
Bulgaria BG VA Niger NE Tokelau TK
City State)
Burkina Faso BF Honduras HN Nigeria NG Tonga TO
Burundi BI Hong Kong HK Niue NU Trinidad and Tobago TT
Cabo Verde CV Hungary HU Norfolk Island NF Tunisia TN
Northern Mariana
Cambodia KH Iceland IS MP Turkey TR
Islands
Cameroon CM India IN Norway NO Turkmenistan TM
Turks and Caicos
Canada CA Indonesia ID Oman OM TC
Islands
Iran, Islamic
Cayman Islands KY IR Pakistan PK Tuvalu TV
Republic of
Central African
CF Iraq IQ Palau PW Uganda UG
Republic
Chad TD Ireland IE Palestine, State of PS Ukraine UA
Chile CL Isle of Man IM Panama PA United Arab Emirates AE
China CN Israel IL Papua New Guinea PG United Kingdom GB
Christmas Island CX Italy IT Paraguay PY United States US
Cocos (Keeling) United States Minor
CC Jamaica JM Peru PE UM
Islands Outlying Islands
Colombia CO Japan JP Philippines PH Uruguay UY
Comoros KM Jersey JE Pitcairn PN Uzbekistan UZ
Congo CG Jordan JO Poland PL Vanuatu VU

Page 6 of 7
Congo, the
Venezuela, Bolivarian
Democratic CD Kazakhstan KZ Portugal PT VE
Republic of
Republic of the
Cook Islands CK Kenya KE Puerto Rico PR Viet Nam VN
Costa Rica CR Kiribati KI Qatar QA Virgin Islands, British VG
Korea, Democratic
Cote d'Ivoire !Côte
CI People's Republic KP Reunion !Réunion RE Virgin Islands, U.S. VI
d'Ivoire
of
Croatia HR Korea, Republic of KR Romania RO Wallis and Futuna WF
Cuba CU Kuwait KW Russian Federation RU Western Sahara EH
Curacao !Curaçao CW Kyrgyzstan KG Rwanda RW Yemen YE
Lao People's
Saint Barthelemy
Cyprus CY Democratic LA BL Zambia ZM
!Saint Barthélemy
Republic
Saint Helena,
Czech Republic CZ Latvia LV Ascension and Tristan SH Zimbabwe ZW
da Cunha
Denmark DK Lebanon LB Saint Kitts and Nevis KN
Djibouti DJ Lesotho LS Saint Lucia LC
Saint Martin (French
Dominica DM Liberia LR MF
part)

Page 7 of 7