CHECK LIST FOR AUTHORISED PERSON REGISTRATION (NSE & BSE) FOR
CASH,
DERIVATIVE AND CURRENCY FOR INDIVIDUAL / SOLE PROPRIETOR
FAN Code :
FAN Name :
Location
Zone
Tel No:
Sr.
No
RM Name :
Date of Receipt
Checklist
BSE
NSE
MANDATORY DOCUMENTS AS PER EXCHANGE
1
Cheque for Authorised Person Registration Fees in favor of “India Rs.2300
Infoline Ltd” payable at Mumbai (Non refundable).
For an amount calculated @ Rs 2300- for each segment of every
exchange as below: ( 1 cheque required for all segments instead
of separate cheques)
Rs.6900
Registration and cancellation fees status :
It must be deposited under AXIS Bank INDIA INFOLINE LTD A/c no.
062010200005203
2
Agreements each On Non judicial Stamp Paper Of Rs 100/Signed and stamped of Individual / Proprietor on each page
a) Trading Member and Authorised Person Agreement-BSE

b) Trading Member and Authorised Person Agreement -NSE
c) Alliance Partner agreement
d) IIFL-Empanelment-Form.pdf
3
Following documents need to be self attested and In person verification
by B.D.M. on each Proofs
(a)
Copy of PAN card (Age not less than 18 years )

(b)
Copy of education proof (Min. Education - 10th pass)

Mark sheet or Passing certificate of examination passed
only)
(c)
Proof of Office Address (on trade name in case of

proprietor)
– One of the following
 Landline Telephone Bill*
 Electricity bill*
 Bank pass book*
 Voters id
 Driving License#
 Passport #
 Bank Statement*
 Shop Establishment Certificate
 Ration Card






(d)
 Rent Agreement with Residence Address proof
* Only the latest ( not more than 3 months old )
 # Valid for next 3 months
Proof of Residence Address – (Authorized Person should
be citizen of India)
 Landline Telephone Bill*
 Electricity bill*
 Bank pass book*
 Voters id card
 Driving License #
 Passport #
 Bank Statement*
 Ration card
*Only the latest ( not more than 3 months old )
 # Valid for next 3 months


4.
5.
1.
(a)
BSE (Annexure 2b(i)

(b)
BSE (Annexure 2b(ii)

(b)
NSE (Annexure 2)
Application Form for BSE (Should be completely filled in and

details should match with the proofs provided)
NON - MANDATORY DOCUMENTS , REQURIE AS PER NEED
In case of married women -



√
√


Marriage affidavit on stamp paper duly notarized. And it should
be on Non judicial Stamp Paper.
2.
1. Change in name on account of marriage
• Marriage Certificate or
• Copy of Passport showing husband’s name or
• Publication of name change in official gazette.
2. Change in name on account of reasons other than marriage
• Publication of name change in official gazette.
3. Change in father’s name
• Publication of name change in official gazette.
3.
A) In case of minor mismatch in name, affidavit of name change
duly attested by notary (name mismatch in PAN card with other
proof given) Non judicial Stamp Paper or Gazette Notification in
case of major differences.
B) In case of minor mismatch in father/ relative‘s name, affidavit
of name change duly attested by notary (name mismatch in PAN
card with other proof given) Non judicial Stamp Paper. or Gazette
Notification in case of major differences.
INTERNAL DOCUMENTS
1.
Online FAN payout form (For detailed please refer circular dated
February 09, 2009, ref no. 2009/02/019, subject: Compulsory
online FAN payout for FAN-P). Required documents –
1)Cancelled cheque
2) Latest Bank statement [not more than 3 months old]
(Required only if name on cancelled cheque is not pre-printed)

2.

3.
Undertaking of Not to deal with Trading Member (TM) other than
TM/Broker where registered
FAN Application Request letter on FAN letterhead
4.
Covering letter
5
Registration Fees

6
Deposit

7.
Undertaking



(1.) Individual
(2.) Proprietor
For Relationship Manager at local branch only
I ……………………………….. (Name) ……………. (Employee Code) hereby confirm that I
have checked the complete set of registration documents and all documents required per the
checklist is attached. I know the applicant for last… months/years personally and am
financially sound and having moral character and integrity
Name and Signature
FAN PROPOSAL CUM EVALUATION FORM
Type: FAN – P
Name of the FAN
Status of the FAN (Individual / Sole
Proprietorship / Partnership / Corporate)
Key contact person
Business location address
City:
Taluka:
Dist:
State:
PIN Code:
Residence address
City:
Taluka:
Dist:
Contact detail
State:
Office
:
Resi
:
Mobile
:
Pin Code:
E – Mail ID :
Whether business & residence address
same
Yes / No
PAN Card No.
FAN Terms
Deposit
Cheque : Rs.
Shares ( ‘A’ Category ) : Rs.
Sharing Terms
VSAT Required (Yes / No)
INFRASTRUCTURE DETAILS
Office (Owned / Rented)
Office Area
Sq. ft. :
NCFM Certificate details
NSE Cash
Name:
No:
BSE Cash
Name:
No:
Derivatives
Current Broking Tie Ups
Yes
/ No
(If Yes)
Specify the details of company with
existing Proposal
Name:
No:
No. of Clients
Brokerage Structure
Brokerage sharing pattern
Gross Brokerage avg. per month (for 6
months)
Is there any IndiaiInfoline Branch
nearest to your office? Yes / No
(If Yes)
Specify the distance in kilometers with
complete address of Branch
Is there any other IndiaInfoline
Franchisee nearest to your office?
Yes / No (If Yes)
Specify the distance in kilometers with
complete address of Franchisee
Expected customer acquisition
L = Lakhs
M = Months (Duration)
Meeting with FAN by Senior IIL official
other than FAN introducer or the RM
who is managing the FAN
Net-wroth
Upto 5L
5L – 10L
Above 10L
Upto 3M
3M – 6M
Date of Meeting
Location
Name of the official meet:
Employee code:
Designation
Comments on Background and Business potential:
Signature
Financial Status / Net Worth
Educational Qualification
FAN Referred by
Name:
Emp. Code:
FAN Introduced by
Name:
Emp. Code:
FAN Managed by
Location / Code of branch who handles
this FAN
Name:
Emp. Code:
Name:
Branch Code:
Name
RM who are
managing FAN
Immediate
Authority of
above RM
For Office use:
FAN code
Approved By
Date
Name :
Signature :
Employee
Code
Cell
Number
Email id
Guideline for FAN Proposal filing:







Brokerage sharing terms & deposit should be clearly written in FAN application letter.
FAN application letter should be signed by proprietor / all partners / all directors with
stamp.
PAN card scan should clearly visible.
If FAN office & residence address both are same then clearly write this in Fan proposal
form.
Do not add sebi fees in security deposit in FAN application letter.
Brokerage sharing of FAN should be clearly written. E.g. If Fan sharing is 55% then it
should be written as 55 % for Fan & 45% for company.
Meeting with FAN by BM & above is mandatory and TM should visit FAN within 15
day of its activation.
Guidelines for FAN-P Infrastructure:



Infra Requirement: - 3 Computers, Dot Matrix printer, Scanner, 3 Telephone lines &
UPS
Manpower: - 2 Dealers / RM’s & 1 Support Staff
If Certificates are not available then submit the same at the time of Compliance
formalities.
(On FAN’s letterhead)
Date:
To,
India Infoline Ltd.
3rd Floor, IIFL House
Sun Infotech Park,
Road No.16V, Plot No. B 23,
MIDC, Thane Industrial Area,
Wagle Estate, Thane-400604.
Sub: Application for Business Association with your company
Dear Sir,
With reference to the above, I am interested in associating with you for all your products
including BSE Remisiership, BSE Subbrokership, NSE Subbrokership, MCX-SX
Subbrokership, BSE Authorized Person, NSE Authorized Person, MCX-SX Authorised
Person, Mutual Fund and Insurance distribution.
I am aware that proposal and commercial terms is recommended to management which is
brokerage sharing ratio as -------------- & deposit ----------------------- acceptable to me/us &
which is subject to approval of management of IIL with same term or on modified term.
You can note my email Id & mobile No. for future communication as below:
Email Id:
Mobile Number:
Looking forward to a mutually beneficial relationship with you.
Thanking you,
Yours faithfully
Signature of the applicant
Proprietor/Partner/Director with Rubberstamp
(ON LETTERHEAD OF APPLICANT)
APPLICATION FORM BY THE APPLICANT FOR REGISTRATION AS
AUTHORISED PERSON WITH TRADING MEMBER OF BSE LTD.
(As per Rules, Bye Laws & Regulation of the Exchange)
1
Name of applicant
(applying for registration of Authorised
Person.)
2
Trade name :
(of Authorised Person/ Partnership firm/
Corporate body)
3
Segment
1. Cash Segment
3. Both
3
4
2. Derivatives Segment
Type of organization
Type of organization:
(sole
proprietor/partnership/LLP/corporate
body) [Kindly provide name/s of proprietor Names of Partners/Directors:
/partners/directors]
1_______________________________
2_______________________________
Office address (with proof)
(place from where authorised person will be
operating - covering area, street/road,
city/dist., state & PIN etc., all fields are
compulsory).
5
Contact Person Name,
Office Telephone,
Mobile Numbers,
Fax Numbers , Email ID
6
Residence address (with proof) with
telephone number
(i.e. of proprietor/all partners/all directors covering area, street/road, city/dist., state &
PIN etc., all fields are compulsory).
7
Education qualification & Date of Birth (with
proof)
(of proprietor / all partners / all directors with
proof are compulsory)
8
PAN Number of the applicant & applicant
firm and of proprietor/all partners/all directors
with proof is compulsory.
9
Name and clearing no. of main Trading
Member to whom applicant is affiliated
10 Date of signing agreement with the Trading
Member
11 Authorised person affiliated to a Trading
Member in any other stock exchange - if Yes,
provide details of Registration No. & Date
with details of name of member to whom
he/she/they is/are affiliated.
12 Whether any case/claim/arbitration pending
against the authorised person in any
court/stock exchanges (provide details)
13 In case applicant is member of a
Regional/Multiple Stock Exchange, details of
SEBI Registration No. & Date of Registration
I certify that the information given in this application form is true to the best of my/our
knowledge and belief.
Date :
Signature of applicant
Place:
(With stamp)
UNDERTAKING
(ON LETTERHEAD OF APPLICANT)
[An applicant should submit this confirmation/declaration/undertaking while
submitting an application for Authorized Person registration]
Dy. General Manager
Membership Compliance Dept.
Bombay Stock Exchange Ltd.
Mumbai
I/We hereby confirm/declare/undertake that (Name of proprietor/all partners/all directors
as applicable should be mentioned) have not been convicted of any offence involving
fraud or dishonesty and no trial is pending against above applicant/s in any court of law.
I/We hereby confirm/declare/undertake that the SEBI has not taken any action like
cancellation of registration / or debarred or prohibited any of the applicant /s from
dealing in securities market/imposed penalty after adjudication/prosecution etc. against
any of the applicant/s (names as applicable)
In case of non-compliance on any of above or in case this
confirmation/declaration/undertaking is found to be false, the Exchange may take
necessary Disciplinary action as per the Rules, Byelaws and Regulations of BSE
Limited
Signature of Applicant
Individual / Proprietor
(with rubber stamp)
Date:
Annexure - 2
Undertaking
(on the letterhead of the Authorized person)
I Mr./Ms. ________________________ (name of the applicant authorised person) had applied
for appointment as Authorised Person of the Stock Exchange on
(Tick the segment (s) applied for)



Capital Market
Futures & Options
Currency Derivatives
segment (s) through trading member, M/s.India Infoline Limited, In this regard, I hereby
confirm/undertake that:
1. I have not been convicted for any offence in the past and presently and not under trial for
any offence involving fraud and dishonesty.
2. I will deal with investors on behalf of Trading Member only and that I would not engage in
any activities with investors which could result in unauthorised intermediations.
3. I am neither an Authorised Person of any other member of the stock exchange and nor
has/have applied for appointment as Authorised Person with any other member of the stock
exchange.
4. I confirm that I am not a defaulter/expelled on any stock exchange.
5. I confirm that I am “fit and proper” under SEBI (Intermediaries) Regulations, 2008 and no
action has been taken against me by SEBI, RBI, etc. and I have not defaulted in payment to
any agency.
Date: ______________
Place: ______________
_________________________________
_________________________________
* Name, Signature & Seal
Undertaking
(On the letterhead of the Authorised Person)
I/We, Mr./Ms./M/s ________________________ (name of the applicant/ authorised person)
had applied for appointment as Authorised Person of the National Stock Exchange of India
Limited (“NSE”) Bombay Stock Exchange (“BSE”) , (NSE and BSE collectively referred to as
“Exchanges”) on Capital Market / Futures & Options / Currency Derivatives Segment(s)
through India Infoline Limited (“the Trading Member”). In this regard, I/We hereby
confirm/undertake that:
1. I/We, partners / directors is/are/am fit and proper person(s) to be registered as an
Authorized Person.
2. I/We, partners / directors have good financial background & reputation, moral character
and integrity and have not been convicted of any offence involving fraud or dishonesty.
3. I/We am/are neither a Trading Member or Sub broker/Authorised Person of the
Exchanges nor a Proprietor/Partner/Director of any other Trading Member or Sub
broker/Authorised Person of the Exchanges
4. I/We also undertake that, we shall obtain prior permission of the Trading Member /
Exchange for any changes like change in trade name/name, address and status and
constitution and I/We shall meet the eligibility criteria of being appointed a Authorised
Person at all times.
5. I/We shall maintain necessary infrastructure like adequate office space, equipment and
manpower to effectively discharge the activities as may be directed by the Trading
Member;
6. The funds and securities of the clients shall be settled directly between the Trading
Member and client. I/We shall provide all the administrative assistance in procurement
of documents and settlement, but shall not issue any document to client in my/our own
name. No fund/securities of clients shall go to my/our account;
7. I/we shall not receive or pay any money or securities in my/our own name or account
and all receipts/payments of securities and funds shall be in the name or account of the
Trading Member,
8. I/We shall not charge any amount as brokerage from the clients
9. I/We shall, at all times, comply with all the conditions laid down for Authorized
Person.
10. I/We shall comply with the Rules, Byelaws, Regulations, directions and circulars issued
by Securities & Exchange Board of India, Exchanges and Trading Member from time
to time;
11. I/We, partners/ directors shall hold the valid NCFM/NISM/BSE certification at all
times and ensure to renew the same from time to time;
12. I/We shall display at each office additional information such as particulars of
authorised person in charge of that branch, time lines for dealing through authorised
person, etc., as may be specified by India Infoline Limited/ Exchanges/SEBI;
13. My/Our name and / or names of the partners / directors is not appearing in SEBI
debarred persons, Directors/ Vanishing Companies List;
14. My/Our name and / or names of the partners / directors is not appearing in CIS and Non
CIS list or CIBIL database;
15. I/We have not, at any time introduced or otherwise dealt with fake, forged, stolen,
counterfeit, etc. shares and securities in the market,
16. Before seeking a withdrawal as an Authorised Person I/We shall give a notice of
minimum forty-five days to the Trading Member.
17. I/We shall provide all co-operation for any periodic inspection conducted by the
Trading Member /Exchanges/SEBI of offices and records of the operations carried out
by me/us;
18. I/We understand that the Trading Member may seek withdrawal of my/our registration
as Authorised Person on noticing any irregularities in my/our operations and shall
withhold all moneys due to me/us till resolution of investor problems, shall file a
complaint with the police, and shall take all such measures required to protect the
interest of investors and market as the Trading Member may think fit;
19. I/We shall be responsible for all deals, acts of commission and omission, quotations
made and transactions effected, if any, by / through me/us and/or our employees,
including liabilities arising there from and I/We hereby undertake to indemnify and
keep indemnified the Trading Member, its Directors and employees at all times in this
regard;
20. I/We hereby confirm that the information that has been submitted by me /us is true to
the best of my/our knowledge and if at a later date if any material information comes to
my/ our knowledge subsequent to the date of this undertaking, I/We undertake to keep
the Trading Member informed about the same.
Date: ______________
Place: ______________
_________________________________
*Name, Signature & Seal
*Should be signed by Individual / Proprietor of the Authorised Person.
(Specimen of Marriage Affidavit to be signed by Applicant on Non judicial Stamp Paper of
appropriate value and duly notarized by a Notary Public)
MARRIAGE AFFIDAVIT
I Mrs. ________________________D/o. Mr._____________________and Wife of Mr.
______________________________, presently residing at
___________________________________________________________________________
___________________________________________________________________________.
Solemnly declare and affirm as under:-
1. That we are married under Hindu Marriage Act/rights/custom and are living together as
married couple since ________________________.
2. That our marriage was solemnized at _____________(place) on ________(Date), at
_________________________.
3. That confirm that before my marriage my midden name was
_________________________ and i have done marriage with Mr.
_________________________ and after my marriage my name/surname was change to
_________________________.
I hereby Confirm that both the above mentioned name before marriage name
___________________ and after marriage name ___________________. Arte belong to me
only. And henceforth i am using my after marriage name for all future action.
Place:
Date:
SIGNATURE OF DEPONENTS
1.____________________
(MR. __________________)
2.____________________
(MRS.__________________)
(Specimen of Change of Name to be signed on stamp paper of appropriate value and
duly notarized by a Notary Public)
NAME CHANGE AFFIDAVIT
I, Mr./Ms./Mrs. __________________________ an adult Indian inhabitant, aged about _____ years;
presently address at
___________________________________________________________________________________________________
(Residence Address) do hereby solemnly declare and affirm that,
As per pan card my name is _________________,
As per education proof my name is ______________,
As per address proof (Bank statement/voter id/BSNL bill/passport/ ration card) my
name is______________,
But my correct name is ______________ which is mentioned on pan card & the name
________________ is wrongly printed on ________________ [Proof name], so I clarify that my
correct name is ______________ and,
The names _________________ALIAS __________________ ALIAS ________________are different names
of the same person as used in few documents from time to time. Though there is little
difference in the names as mentioned above, I hereby solemnly affirm and declare that all
these names belong to me only.
Affirmed by me at _________, this ______________________ 201_ (Date).
Identified by me
Advocate High Court
Deponent
(Specimen of Change of Name to be signed on stamp paper of appropriate value
(Non judicial Stamp Paper and duly notarized by a Notary Public)
FATHER NAME MISMATCH
I, Mr./Ms./Mrs. __________________________ an adult Indian inhabitant, aged about _____ years;
presently
address
at
___________________________________________________________________________________________________
(Residence Address) do hereby solemnly declare and affirm that
As under,
As per pan card my father name is _______________
As per education proof my father name is ____________
As per address proof (Bank statement/voter id/BSNL bill/passport/ ration card) my
father name is______________
I clarify that my father correct name is ______________ and the names __________________ ALIAS
___________________ALIAS ____________ are different names of the same person. as used in few
documents.
Though there is little difference in the names as mentioned above, I hereby solemnly
affirm and declare that all these names belong to my father only.
Affirmed by me at Mumbai, this ______________________ 201_ (Date).
Identified by me
Advocate High Court
Deponent Signature
(Specimen for Date of Birth Mismatch to be signed on stamp paper of
appropriate value and duly notarized by a Notary Public)
Date of Birth Mismatch AFFIDAVIT
I, Mr./Ms./Mrs. __________________________ an adult Indian
inhabitant, S/O or D/O__________________ aged about _____
years;
presently
residing
at
_______________________________________________________
_______________________________________________________
_ , do hereby, solemnly declare and affirm that, my birth date
mentioned in my Education Proof or Driving License or Voter ID Or
Passport as ________________ , however, it is punched by PAN
(Permanent Account Number) CARD DEPARTMENT in my PAN CARD
as ____________. There is a difference in my both birth date proof.
So,I hereby, solemnly affirm and declare that my correct and true
birth date is ___________________ mentioned in PAN Card or
Education Proof or Driving License or Voter ID.
I hereby, gives my personal assurance to whomsoever it may
concern that my correct and true birth mentioned in my PAN Card or
Education Proof or Driving License or Voter ID or Passport as
_________________ is applicable to me for any kind of transactions
which requires birth date verification.
Affirmed by me at _________, this ____________________ 2015
(Date).
Identified by me
Advocate High Court
Deponent Signature
On the letterhead of IIFL
For Short Address Undertaking In BSE
Member Confirmation for AP Address Proof
To,
Membership Compliance,
Bombay Stock Exchange Ltd.
Date:
Dear Sir,
Trade Name of Authorised Person : --------------, having address----------------,
We herby confirm that our representative has personally verified aforesaid address and it is complete in
all respect. We are also attaching
as an address proof as per Exchange requirement.
I/We hereby recommend aforesaid applicants application for granting registration of Authorised Person.
Yours faithfully
For INDIA INFOLINE LTD
Authorised Signatory
On the letterhead of applicant
For Short Address Undertaking In NSE
Member Confirmation for AP Address Proof
To,
Membership Compliance,
National Stock Exchange Ltd.
Date:
Dear Sir,
Trade Name of Authorised Person : -------------------, having address : --------------------We herby confirm that our representative has personally verified aforesaid address and it is complete in
all respect. We are also attaching _
as an address proof as per Exchange requirement.
I/We hereby recommend aforesaid applicants application for granting registration of Authorised Person.
Yours faithfully
Signature of Applicant
Proprietor / Partner / Director
(with rubber stamp)
Date:
Bank Sign Verification letter for BSE and NSE
Date :
From :-
To,
Subject : Request to verify my signature
Respected sir,
As I am maintaining my saving account to _______________. My saving account No
……………………….Now I need verification for my signature to submit documents
to India Infoline ltd for Authorised Person Registration
You are requested to verify the same.
Specimen Signature as per pan card
Specimen Signature as per bank account
__________________
___________________
Specimen Signature as per Authorised Person Registration documents ___________________
Thanking you,
Yours Faithfully,
On FAN Letter head
To,
India Infoline Ltd.
3rd Floor, IIFL House, Sun Infotech Park,
Road No. 16V, Plot No. B-23,
MIDC, Thane Industrial Area, Wagle Estate,
Thane - 400604.
Sub: Request for ONLINE TRANSFER of payout.
Dear Sir,
With reference to the above subject, you are requested to transfer my monthly payout to below
mentioned bank account
FAN Code
FAN Name
Fan Address
Pin code:
State:
Bank Details:
Beneficiary Name
(Name of A\C
Holder)
Bank Name
Bank Account
Number
Bank Account Type
o
Savings
o
Current
Bank Branch Address
Pin code:
State:
MICR Code *
IFSC Code **
* 9 Digit Code number of the Bank & branch appearing on the cheque issued by the bank
** This code is printed on the cheque and if the same is not printed on the cheque it should be
obtained from the respective bank of the account holder. Also if the FAN is having an ‘at par’
account with any bank, the IFSC code mentioned on the cheque would be the common IFSC
code of the Bank; in such cases the IFSC code of the respective local Branch needs to be
obtained from the Bank.
ENCL: 1) Cancelled cheque leaf
2) Latest account statement.
Thanking You,
Authorized Signatories
(On FAN’s letterhead)
Date :
From
……………………………….
………………………………
………………………………
…………………………………
To
M/S India Infoline Ltd
Mumbai.
Ref: Fancode - ………………
Subject: Franchisee Deposit of ……………………………………………………
1 I/ We am /are enclosing / deposited herewith chq / DD No………………………..
Dated. ………………… For the amount Rs …………………………………….
(Words: ………………………................................................................................)
drawn on bank …………………………………………………… ... In favour of
India Infoline Ltd A/c No………………………Of..……………………….Bank
Please Acknowledge
Place
Name
Sign
On FAN Letter head
Undertaking
Subject: Not to deal with Trading Member (TM) other than TM/Broker where registered
I / We ____________________________________________________an individual/
company/ firm having residence address/ registered office
at___________________________________________________________________________
I/we hereby undertake that I/we are not dealing any proprietary trading or for trading on behalf
of clients other than India Infoline Ltd where I/we are registered.
If at any time it found violation of above provision then then SEBI/Exchange can initiate
necessary disciplinary action against me / us as per provision.
Sub-broker name:
Date:
Place:
Signature:
(Stamp in case of Proprietor)
ON THE LETTERHEAD OF AUTHORISED PERSON
___________________________________________________________________________
I, ______________________________ , son of ___________________________ aged __,
resident of __________________________________________________________________,
Hereby declare that there was /is no adverse action whatsoever, such as enquiry/adjudication
(penalty imposed) / Suspension / Cancellation / Prosecution / de-barring from capital market,
initiated / pending / completed against me ______________________________, by SEBI or
any other authority / institution, either in past or at present.
Further, I, ______________________________ also confirm that, I am/was not ever
associated
/
connected,
in
any
capacity
whatsoever,
with
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
I further confirm that ______________________________ is/ was not ever associated with
_____________________________________________________________
_________________________________________________________________
_________________________________________________________________
I further confirm that ______________________________ is / was never associated with
any stock exchange.
I fully understand and am aware that giving false declaration is an offence and can result in
certain actions including the rejection of application and / or / cancellation of my application /
registration.
Place:
Date:
Pan No:
(Signature)
ON THE LETTERHEAD OF AUTHORISED PERSON
________________________________________________________________
I, ______________________________ Son of ______________________________ aged
__,years
resident
of
_________________________________________________________________
,
is
Proprietor of ______________________________
Hereby declare that there was /is no
adverse
action
whatsoever,
such
as
enquiry/adjudication
(penalty
imposed)/Suspension/Cancellation/Prosecution/ de-barring from capital market, initiated /
pending / completed against me ______________________________
or against my firm
______________________________ by SEBI or any other authority / institution, either in
past or at present.
Further, I, ______________________________
also confirm that, I am/was not ever
associated
/
connected,
in
any
capacity
whatsoever,
with
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
I further confirm that ______________________________ is/ was not ever associated with
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
I further confirm that ______________________________
Proprietor
______________________________ is / was never associated with any stock exchange.
of
I fully understand and am aware that giving false declaration is an offence and can result in
certain actions including the rejection of application and / or / cancellation of my application /
registration.
_________________________
(Signature & Stamp)
Place:
Date:
(Signature)
Pan No :