Requisition form for Addition/Deletion/Modification of Account Details

(TO BE FILLED IN CAPITAL BLOCK LETTERS IN BLACK/BLUE INK ONLY)

Reliance Securities Limited, 11th floor, R-Tech I T Park, Western Express Highway, Goregoan (E), Mumbai - 400 063, Maharashtra, Tel.: 022-33201212

DP ID 1 3 0 4 1 4 0 0

BO ID

Date D D M M Y Y Y Y

First Name

Name of First Holder

Middle Name

Last Name

Pan No.

Trading Client ID

Date of Birth D D M M Y Y Y Y

I/We request you to make the following Addition/Deletion/Modification to my/our account in your records. Account details are as under:
ADDRESS & CONTACT DETAILS
Category

New Details
Line 1

o
Correspondence
o
Permanent

Line 2

Pincode

Contact Details

Line 3

City

State

Country

New Email ID

New Mobile No.

Self o
Spouse o
Children oo
Parents
Owners PAN
Self o
Spouse o
Children oo
Parents
Owners PAN

Mobile No. belongs to:

Email id belongs to:

o
Signature

Old Signature

New Signature

UID Card, o
Address Proofs: o
Passport, o
Voter ID card, o
Driving license, o
Bank passbook/statement with cancel cheque, o
Electricity bill (not more than
two months), o
Telephone bill - Land line (not more than two months) Identity Proof: o
Pan Card, o
Passport, o
Voter ID card, o
Driving license, o
UID Card
I/We wish to update the above changes in KRA/ Demat / Trading account.
BANK DETAILS
Primary o
Secondary
o
Addition
o
o
Modification
o
Deletion

Existing Details

New Details

Bank Name

Bank Name

Account Number

Account Number

IFSC

IFSC

MICR

MICR

Bank details: o
Copy of cheque with name printed, o
Copy of bank passbook with cancel cheque, o
Copy of bank statement of accounts duly attested by
bank authorities not older than two months with cancelled cheque

EXCHANGE SEGMENT
Activation
o

NSE FO
BSE FO
NSE Currency
o
o
o

Deactivation
o

NSE SLBS
o

OTHER MODIFICATION: Running Account Authorisation - Settlement Preference (Tick any one)
Once in a calendar Quarter o
Once in a calendar Month
o
This authorisation shall remain valid until it is revoked by me/us

Income Declaration
0 - 1 Lac
1 Lac - 5 Lacs
o
o
10 Lacs - 25 Lacs o
25 Lacs and above
o

5 Lacs - 10 Lacs
o

Declaration : I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief. In case any of the above information is found to be false or
untrue or misleading or misrepresenting, I am/we are aware theat I/we may be held liable for it. Documents pertaining to Rights & Obligations were made available to me/us.
I/we hereby authorize and request Reliance Securities to provide the above details to Reliance Commodities, for updating the same in my Commodity trading account with them.

First/Sole Holder

Second Holder

Third Holder

Name
Signature
OFFICE USE ONLY (FOR IN PERSON VERIFICATION)

QRC No:

(Originals Verified) Self Certified Document copies received

o
(Attested) True copies of documents received
o

Employee Name___________________________________

Branch Code:

SAP ID: ______________ Designation: _______________

Signature

ACKNOWLEDGMENT RECEIPT FOR CUSTOMER

Date:

Trading Client ID:

QRC No:

Name of client

BO ID:

Type of Request
Branch Name
Reliance Securities Limited

Signature & Seal

Ver 3.3 / November 2015