Combined 2-in-1 Demat & Trading Account Opening Form

Account Type ✘ Trading & Demat

Only Trading

Only Demat

Account Mode Offline ✘ Online

Application Number 1935045186

PHOTO
Application type ✘ New Update

Account Type ✘ Normal Simplified Small

Personal Details
Prefix First Name Middle Name Last Name

Name Mr. NAVEEN KUMAR C

Father /
Spouse Mr. CHOWDAPPA CHOWDAPPA

Mother Mrs. RAJAMMA

Date of Birth 18-04-1998

Gender ✘ Male Female Transgender
Marital Status Married ✘ Unmarried Others
Citizenship ✘ Indian Others (ISO 166 country code)
Occupation Type Service Private Sector
Public Sector
Govt Sector

Others Professional Self Employed

Retired Housewife ✘ Student

Business Not categorized

1 ______________________________
Customer Signature
 Name of Document Document Number Expiry date (if
any)
Passport

Voter ID Card

Driving License

✘ Aadhaar 711026168016

Others

✘ Pan Card BXWPN9403J

Proof of address (POA)

Correspondence Address Type:

✘ Residential / Business Residential Business
Registered Office Unspecified
Proof of Address (Correspondence):
Name of Document Document Number Expiry date (if any)
Passport

Voter ID Card

Driving License

✘ Aadhaar 711026168016

Others
Correspondence Address Details:

Line 1 S/O: Chowdappa, #17/6,

Line 2 Thimmarayaswamy temple road

Line 3 Nekara colony, Anekal,

Pin 562106 City/Town/Village Bengaluru South

State/U.T. Karnataka Country INDIA

2 ______________________________
Customer Signature
Permanent Address Type:
✘ Residential / Business Residential Business
Registered Office Unspecified
Proof of Address (Permanent):
Name of Document Document Number Expiry date (if any)
Passport

Voter ID Card

Driving License

✘ Aadhaar 711026168016

Others
Permanent Address Details:
Line 1 S/O: Chowdappa, #17/6,

Line 2 Thimmarayaswamy temple road

Line 3 Nekara colony, Anekal,

Pin 562106 City/Town/Village Bengaluru South

State/U.T. Karnataka Country INDIA

Contact Details:

Mobile 9035902292

Email-ID NAVEENKUMARNC1997@GMAIL.COM

3 ______________________________
Customer Signature
1.Trading preferences:
Name of Segment Name of Exchange
✘ NSE
Cash & Mutual Funds
✘ BSE
# If, in future, the clients wants to trade on a new segment/ new exchange separate
authorization/ letter should be taken from the client by the stock broker.

2. Other Details
a. Educational Under Graduate or less
Qualification Graduate
✘ Post Graduate
b. Gross Income Below Rs. 1 Lac
Annual Range ✘ 1-5 Lacs
Income 5-10 Lacs
Details 10-25 Lac
(please >25 Lacs
specify)
Per Date:
annum
Net -
worth as
on (Net worth should not be older than 1year)
(date)
c. Politically Exposed Politically Exposed Person
Details Related to a Politically Exposed Person
✘ None

3. Bank Details
(Through which Transactions would be routed. Details and proof of bank accounts is Required)
Account Type: ✘ Savings Current

Bank A/C Number 54940100002563

MICR Number 560012042 IFSC BARB0ANEKAL

Bank Name BANK OF BARODA

Demat Access Branch 0764

4 ______________________________
Customer Signature
4. Past Actions
Details of any actions/proceedings/initiated /pending/taken by SEBI/ Stock Exchange/ any other
authority against the applicant/
Constituent or its Partners/Promoters/ Whole time Directors/authorized persons in charge of
dealing in securities during the last 3 years.
Yes If yes, provide details:

✘ No

1. Account to be Operated through Power of ✘ Yes No

Attorney (POA)
2. I/We instruct the DP to receive each and (Automatic Credit)
every credit in my/Our
account (if not marked, the default option Yes No
would be Yes)
3. SMS Alert Facility Refer to Terms & ✘ Yes No
Conditions Given as Annexure in Rights &
Obligations.
Mobile No. 9035902292
Mandatory, if you are giving power of Attorney
(POA) If POA is not granted & you do not wish
to avail of this facility, cancel this option.

4. Account Statement Requirement ✘ As per SEBI Regulation

Daily Weekly Fortnightly Monthly

5. Whether you wish to receive physical Electronic Transaction-cum-Holding
contract note/ Electronic Statement (ESOTH)
Contract Note (ECN)/ Electronic Transaction ✘ Electronic Contract Note (ECN)
and Holding Physical Contract Note
Statement (Charges applicable)
(If ECN & ESOTH is opted, ”Authorization for
sending documents
Through E-mail” shall be executed)

6. I/We wish to receive dividend/interest ✘ Yes No

directly in to my/our
Bank account as given above through ECS (If
not marked, the
default option would be ‘Yes) [ECS is
mandatory for locations
notified by SEBI from time to time]
7. To register for EASI,please visit CDSL website www.cdslindia.com (EASI allows a BO to

5 ______________________________
Customer Signature
view ISIN Balances, transactions and value Of the portfolio through Internet.)

8. Whether you wish to avail of the facility of ✘ Yes No

Internet Trading / Wireless Technology(please
specify):
9. Investment/ Trading experience 1 YEARS

10. I/We would like to instruct the DP to ✘ Yes No

accept all the pledge
instructions
In my/our account without any other further
instruction from
My/our end (if not marked, the default option
would be ‘No’)
11. I/We would like to share the email ID with ✘ Yes No
the RTA
12. I/We would like to receive the Annual ✘ Electronic
Report of companies held Physical
by me/us. Both Physical and Electronic
(Tick the appropriate box. If not marked the
default option
Would be in Physical)
13. I/We have issued a Power of Attorney Option 1:I /We require you to issue
(POA) in favor Delivery Instruction Slip Booklet to me/us
of Bank of Baroda for Executing delivery through we have issued POA.
instructions for settling stock exchange trades
effected ✘ Option 2:I/We do not require the Delivery
through clearing member, margin obligations Instructions Slip for the time being.
etc.
14. I / We wish to receive the following ✘ Electronic
documents Physical
a. Rights & Obligations
b. Rights and Obligations of the Beneficial
Owner and Depository
Participant
c. Risk Disclosure Document
d. Guidance Note
e. Policies & Procedures
f. Additional (Voluntary) Rights & Obligations
Terms and Conditions-cum-Registration /
Modification Form for
receiving SMS Alerts from C DSL Definitions
5. Nomination Option I/We wish to make a nomination.

6 ______________________________
Customer Signature
Applicant 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 declare that I am not
making this application for the purpose of contravention of any Act, Rules, Regulations or any
statute of legislation or any notifications/directions issued by any governmental or statutory
authority from time to time.

Date

Place
Signature / Thumb Impression of the applicant

Attestation (For Office Use Only):

All certified Documents received. IPV Date

In Person Verifier Details:

Employee Name

Employee Code

Employee Designation

Employee Branch

Institution Name

7 ______________________________
Customer Signature