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Name of the Applicant:
Date of incorporation: ———— (dd/mm/yyyy) & Place of incorporation: ——————-
Date of commencement of business: —————————————————————–
a. PAN: ——————————————————————————————————-
Registration No. (E.g. CIN):————————————————————–
Status: ——————————— ( ) Private Limited Co.
( ) Public Ltd. Co.

( ) Body Corporate

( ) Partnership

( ) Trust

( ) Charities

( ) NGOs

( ) FI

( ) FII

( ) HUF

( ) AOP

( ) Bank

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( ) Non-Government Organization

( ) Defence

( ) Establishment

( ) BOI

( ) Society

( ) LLP

—————————————————-Others (please specify) Private Limited Co.

Address for correspondence: ——————————-

City/town/village: —————————————-

Pin Code: ————————————————-

State: ——————————————————

Country: —————————————————

Contact Details:
Tel. (Off.) ————————–

Tel. (Res.) ————————-

Mobile No.: ———————–

Fax: ———————————-

Email id: ———————————

Specify the proof of address submitted for correspondence address: —————————————————————
Registered Address (if different from above): ——————————-
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State: ———————————————————————————–

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Specify the proof of address submitted for registered address: —————————————————————————————————————————————————-
Gross Annual Income Details (please specify):———————————-Below Rs 1 Lac

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5-10 Lac

10-15 Lac

Net-worth Amount ————————————————————–
Net-worth Date as on ———————————————————- (dd/mm/yyyy)

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

Name, PAN, residential address and photographs of Promoters/Partners/Karta/Trustees and whole
time directors:——————————————————————————————————————————————————————————————————————————————————————————————————————————————–

DIN/UID of Promoters/Partners/Karta and whole time directors: ————————————————————————————————————————————————————————————————————————————————————————
Please tick, if applicable, for any of your authorized
Signatories/Promoters/Partners/Karta/Trustees/whole time directors:

( ) Politically Exposed Person (PEP)

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Any other information:——————————————————————————————————————————————————————————————————————————————————————————————————————————-

I/We hereby declare that the details furnished above are true and correct to the best of my/ourknowledge and belief and I/we undertake to inform you of any changes therein, immediately. In caseany of the above information is found to be false or untrue or misleading or misrepresenting, I am/weare aware that I/we may be held liable for it.


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Date: ___________ (dd/mm/yyyy)

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